Scorpions Health Screening Questionnaire Form for Development Program Athletes

Scorpions Health Screening Questionnaire for DEVELOPMENT PROGRAM ATHLETES

Parents, thank you for taking the time to answer these questions. This questionnaire must be completed online by each individual prior to participation in the first club activity. If an individual answers “Yes” to any of these questions, they are not permitted to participate in any club activities. This questionnaire is completed before each session. Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.
Name of Player *

First Name Last Name
Parents Contact Email *
example@example.com
Age Group Playing *
1. Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) *

Yes No
2. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days? *

Yes No
3. Have you had close contact in the past 14 days with anyone with a new cough, fever or difficulty breathing or a confirmed case of COVID-19? *

Yes No
3. Have you had close contact in the past 14 days with anyone with a new cough, fever or difficulty breathing or a confirmed case of COVID-19? *

Yes No

4. Do you have any of the following symptoms?

YES

NO

Cough

Shortness of breath

Runny nose, sneezing or nasal congestion (not related to other known causes such as seasonal allergies etc.)

Sore throat

Difficulty swallowing

Lost sense of taste or smell

Should be Empty: