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Covid-19 Pre-Screening ForM
Dancer Name
Parent/ Guardian Name (if under 18)
Date
1. Does the dancer have any of the following symptoms?
Fever and/or chills: Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup): Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of breath: Not related to asthma or other known causes or conditions you already have
Sore throat or difficulty swallowing: Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)
Decrease or loss of smell or taste: Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Pink eye: Conjunctivitis not related to reoccurring styes or other known causes or conditions you already have
Runny or stuffy/congested nose: Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have
Headache: Unusual, long-lasting not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have
Nausea, vomiting and/or diarrhea: Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have
Extreme tiredness or muscle aches: Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions you already have)
None of the above
2. In the last 5 days, has the dancer travelled outside of Canada and were told to quarantine or told to not attend school/child care?
Yes
No
3. In the last 5 days, has the dancer been identified as a “close contact” of someone who currently has COVID-19?
Yes
No
4. Has a doctor, health care provider, or public health unit told the dancer that they should currently be isolating?
Yes
No
5. Is anyone the dancer lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
Yes
No
If you answered "NO" or "NONE OF THE ABOVE" to all the questions, you may come into the studio!
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