2021 Adults - BCT Return to Play COVID-19 Health Screening
The purpose of this screen is to inform and make you aware of the risks involved in returning to train
Name
*
First Name
Last Name
Email
*
example@example.com
Have you had confirmed COVID-19 infection or any symptoms (listed below) in keeping with COVID-19 in the last five months? 1/ Fever 2/ Persistent, dry cough 3/ Loss of taste or smell
*
Yes
No
If Yes then provide details
Have you had a known exposure to anyone with confirmed or suspected COVID-19 in the last two weeks? (e.g. close contact, household member)
*
Yes
No
If Yes then provide details
Do you have any underlying medical conditions? (Examples include: respiratory conditions including asthma; heart, kidney, liver or neurological conditions; diabetes mellitus; a spleen or immune system condition; currently taking medicines that affect your immune system such as steroid tablets).
*
Yes
No
If Yes then provide details
Do you live with or will you knowingly come into close contact with someone who is currently ‘shielding’ or otherwise medically vulnerable if you return to the training environment?
*
Yes
No
If Yes then provide details
Are you able to train
*
Yes
No
Have you sought medical advice?
*
Yes
No
Signature
*
Submit
Should be Empty: