Peninsula Track & Field Club - Daily COVID 19 Screening Tool
Please complete the form prior to arriving at track practice. If you have answer YES to any of the questions below, please contact Aaron Holmgren and stay home.
Today's Date: *
MM
/
DD
/
YYYY
Athlete Name (first & last name) *
HAVE YOU BEEN DIAGNOSED WITH COVID-19? *
ARE YOU EXPERIENCING ANY OF THE FOLLOWING:• Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)• Severe chest pain• Having a very hard time waking up• Feeling confused• Losing consciousness• 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-LIKE SYMPTOMS, EVEN MILD ONES? Symptoms include: Fever*, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches. While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discoloration of fingers or toes. Fever: Average normal body temperature taken orally is about 37°C. For more on normal body temperature and fevers, see HealthLinkBC's information for children age 11 and younger and for people age 12 and older . *
HAVE YOU TRAVELLED TO ANY COUNTRIES OUTSIDE OF CANADA (INLCUDING THE UNITED STATES) WITHIN THE LAST 14 DAYS? *
DID YOU PROVIDE CARE OR HAVE CLOSE CONTACT WITH A PERSON WITH A CONFIRMED CASE OF COVID-19? *
HAVE YOU BEEN ASKED TO SELF-ISOLATE BY ISLAND HEALTH? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy