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Guest Screening Form
COVID-19 Screening: We ask that you answer the following questions truthfully for the safety of all participants and staff.  If YES is answered for any of the questions, you/your child will not be permitted to visit the facility today.  Please fill out one questionnaire per individual. Parents will need to fill out the form for their child(ren), again, one per child.
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Email *
Guest First & Last Name *
Symptoms:
Fever*
Cough*
Shortness of breath/difficulty breathing*
Runny nose*
Sore throat*
Chills
Painful swallowing
Nasal congestion
Feeling unwell/fatigued
Nausea/vomiting/diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle/joint aches
Headache
Conjunctivitis (commonly known as pink eye)
Does the guest, have any new onset (or worsening) of any of the above symptoms? *
Has the guest traveled outside of Canada in the last 14 days? *
Has the guest had close contact with a case of COVID-19 in the last 14 days? *
If you have answered “yes” to any of the above questions DO NOT ATTEND. Go home and use the AHS Online Assessment Tool to determine if testing is recommended.
*Individuals with fever, cough, shortness of breath, runny nose, or sore throat, are required to isolate for 10 days per CMOH Order 05-2020 unless they receive a negative COVID-19 test and are feeling better.

By clicking SUBMIT, you agree and give consent for Tien Lung Taekwon-Do to share participant information with Alberta Health Services if a potential exposure occurs onsite. Information will not be used for any other purpose, and records will only be kept for 2 weeks.
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