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