FVWP COVID 19 Screening Health Questionnaire
Please fill this out before attending any event held by Fraser Valley Water Polo. Deadline to submit is 21:00 the night before the event.
Email address *
Date of Practice *
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Athlete Name *
Phone Number *
Participant Role *
FVWP Practice Group *
Are you experiencing any of the following: Severe difficulty breathing (eg. struggling to breathe or speaking in single words), Severe chest pain, Having a hard time waking up, Feeling confused, Losing consciousness *
Are you experiencing any of the following: Mild to moderate shortness of breath, inability to lie down because of difficulty breathing, chronic health conditions that you are having difficulty managing because of difficulty breathing *
Are you experiencing cold, flu or COVID-19 symptoms, (even mild ones)? Common symptoms include: Fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of smell and/or taste, headache, fatigue, diarrhea, loss of appetite, nausea and/or vomiting, muscle aches. While less common symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discolouration of fingers or toes. *
Have you travelled to any countries outside Canada (including the United States) within the last 14 days? *
Did you provide care or have close contact with a person with confirmed COVID-19? NOTE: This means that you would have been contacted by your health authority's public health team. *
A copy of your responses will be emailed to the address you provided.
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