OHF Health Screening Questionnaire U8 (Apsley Minor Hockey)

Print OHF Health Screening Questionnaire U8
This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. This questionnaire may be completed verbally. Are you currently experiencing any of these issues? Call 911 if you are. • Severe difficulty breathing (struggling for each breath, can only speak in single words) • Severe chest pain (constant tightness or crushing sensation) • Feeling confused or unsure of where you are • Losing consciousness If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating. • Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors) • Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder) • Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD) • Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)
Player/Parent Information
  1. Please print first and last name
  2. Please print first and last name
  3. Please print first and last name
  4. Please select from drop down menu
  5. RadDatePicker
    RadDatePicker
    Open the calendar popup.
1. Are you currently experiencing any of these symptoms?
The answer to all questions must be “No” in order to participate in any and all activity.
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For the remaining questions, close physical contact means:
Being less than 2 metres away in the same room, workspace, or area for over 15 minutes. Living in the same home.
  1. Please check one
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  3. Please check one
Human Validation
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Printed from apsleyminorhockey.com on Saturday, November 28, 2020 at 12:17 AM