Stratford Aces Health Screening Questionnaire (Stratford Aces Girls Hockey)

PrintStratford Aces Health Screening Questionnaire

Stratford Girls Hockey Association Health Screening Questionnaire

This questionnaire must be completed by each individual (players and parents if attending the arena) prior to participation in each on-ice or off-ice activity. This questionnaire may be completed verbally.

Your Trainer will ask you to confirm that you have completed the questionnaire and answered no to all questions before you will be permitted to enter the arena. If you have answered yes to any of the questions, please inform your Coach and email the Covid Coordinator at [email protected] prior to coming to the arena/facility.

Are you currently experiencing any of these issues? Call 911 if you are.

1. Severe difficulty breathing (struggling for each breath, can only speak in single words)

2. Severe chest pain (constant tightness or crushing sensation)

3. Feeling confused or unsure of where you are

4. Losing consciousness


If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.

1. 70 years old or older

2. Getting treatment that compromises, (weakens) your immune system (for example,

chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

3. Having a condition that compromises (weakens) your immune system (for example, diabetes,

emphysema, asthma, heart condition)

4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery,

cancer treatment)


The answer to all questions must be “No” to be able to participate in each on-ice or off ice activity.

Are you experiencing any of these symptoms?

Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)


Cough that’s new or worsening (continuous, more than usual)

Barking cough, making a whistling noise when breathing (croup)

Shortness of breath (out of breath, unable to breathe deeply)

Sore throat

Difficulty swallowing

Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)

Lost sense of taste or smell

Pink eye (conjunctivitis)

Headache that is unusual or long lasting

Digestive issues (nausea/vomiting, diarrhea, stomach pain)

Muscle aches

Extreme tiredness that is unusual (fatigue, lack of energy)

Falling down often

For young children and infants: sluggishness or lack of appetite


For the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes or living in the same home.

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?

In the last 14 days, have you been in close physical contact with a person who either:

Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks?

Have you travelled outside of Canada in the last 14 days?


If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-ice or off-ice activities. Please call your coach immediately and let them now that you have responded positively to questions in the Health Screening Questionnaire. You must also e-mail - your name; age group; date and time of activity to [email protected]

Please note: This Health Screening questionnaire has been developed based on the Ontario Ministry of Health Self-Assessment Tool (June 17, 2020).

Category Sites
Social Networking
Follow Us On
Follow Stratford Aces Girls Hockey on Twitter
- and -
Visit Stratford Aces Girls Hockey on Facebook
Manage Subscriptions
Signup to receive email or text messages for the teams you want to follow.
Printed from on Sunday, June 20, 2021 at 8:01 AM