SCREENING FORM | therhythmensemble

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 14 days, has the dancer travelled outside of Canada?

Yes

No

3. In the last 14 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

Covid-19 Pre-Screening ForM

If you answered "NO" or "NONE OF THE ABOVE" to all the questions, you may come into the studio!

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