Phoenix - Daily Health Assessment Tool
This form MUST be filled out EACH TIME you come to the gym - Participants, Staff AND Visitors
*Will be updated to reflect any Government of Alberta, AHS or AGF changes to questions or requirements
choose one of the following *
First & Last Name: *
Name of Contact we may reach during this session *
Contact's Phone number *
Pick-up Person (if different than contact)
If you have answered “YES” to any of the below questions DO NOT participate. Proceed home and use the AHSOnline 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. Please see this link if that is the case: https://myhealth.alberta.ca/Journey/COVID-19/Pages/COVID-Self-Assessment.aspx
Do you have any new onset or worsening of any of the following: *
YES
NO
Fever (greater than 38.0C) *
Cough *
Shortness of Breath / Difficulty breathing *
Runny Nose/ Nasal Congestion
Sore Throat
Chills
Painful Swallowing
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Muscle / Joint Aches
Loss of sense of taste or smell
Conjunctivitis (know as pink eye)
Headache
Have you, or anyone in your household travelled outside of Canada in the last 14 days? *
Has the attendee had close contact with an individual who has any one of the first 3 symptoms above for children * or adults - first 5 on list AND /OR who is a close contact of a confirmed of a case of COVID-19 in the last 14 days? *
Have you tested positive for COVID-19 within the last 10 days? *
*IF YOU HAVE ANSWERED “YES” TO ANY OF THE ABOVE QUESTIONS DO NOT PARTICIPATE. PROCEED HOME AND USE THE AHSONLINE ASSESSMENT TOOL TO DETERMINE IF TESTING IS RECOMMENDED. *
Required
If this form was submitted on behalf of a participant please indicate your name:
If this form was submitted on behalf of a participant please indicate your phone number:
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy