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)
1. Have you, or anyone in your household travelled outside of Canada in the last 14 days? *
2. Have you had any known close contact with a case of COVID-19 in the last 14 days? Face-to-face contact within 2 metres for 15 minutes or longer, direct physical contact such as hugging, or contact with infectious body fluids. Note: A health care worker in an occupational setting wearing recommended personal protective equipment is not considered to be a close contact.
Clear selection
3. Do you have any new onset or worsening of any of the following: *
YES - SEE BELOW for further instructions
NO - You may enter the site.
Fever (38.0C) / cough / shortness of breath/ Difficulty Breathing
Runny Nose/ Nasal Congestion / Chills/ Headache / Feeling unwell /Sore Throat/ Painful Swallowing / Fatigued
Nausea / Vomiting / Diarrhea / Muscle / Joint Aches / Unexplained loss of appetite / Loss of sense of taste or smell / Conjunctivitis (know as pink eye)
If you answered “YES” to any symptom in question 3: - Stay home or return home. Do not enter the site - Use the AHS Online Assessment Tool or call Health Link 811 to receive additional information on testing and isolation. - Adults (18 and over) with fever, cough, shortness of breath, runny nose, sore throat or loss of sense of taste or smell are required to isolate for 10 days as per CMOH Order 39-2021 OR receive a negative COVID-19 test and feel better before returning to a continuing care site. • Children (under 18) with fever, cough, shortness of breath, or loss of sense of taste or smell are required to isolate for 10 days as per CMOH Order 39-2021 OR receive a negative COVID-19 test and feel better before returning to a continuing care site. • If your child is experiencing any symptoms from the list above, do not bring them to visit the facility for 10 days from when symptoms started or until symptoms resolve (whichever is longer), unless they receive a negative COVID-19 test result and feel better. Please see this link if that is the case: https://myhealth.alberta.ca/Journey/COVID-19/Pages/COVID-Self-Assessment.aspx
*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. - AHS Tool: https://myhealth.alberta.ca/Journey/COVID-19/Pages/COVID-Self-Assessment.aspx *
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:
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