Covid Self Assessment Form

Name: *

Email: *

Phone Number: *

Date: *

Time: *

1) Do you or your swimmer(s) have any of the following new or worsening symptoms or signs? (Symptoms should not be chronic or related to other know causes or conditions):

Fever or Chills

Yes No

Difficulty breathing or shortness of breath

Yes No

Cough

Yes No

Sore throat/trouble swallowing

Yes No

Runny nose/stuffy nose or nasal congestion

Yes No

Decrease or loss of smell or taste

Yes No

Nausea, vomiting, diarrhea, abdominal pain

Yes No

Not feeling well, extreme tiredness, sore muscles

Yes No

2) Have you or your swimmer(s) travelled outside of Canada in the past 14 Days?

Yes No

3) Have you or your swimmer(s) had close contact with a confirmed or probable case of COVID–19?

Yes No