Dynamite Basketball

PLEASE READ

This questionnaire was adapted from the Ontario Ministry of Health Self-Assessment Tool. Each participant must complete this questionnaire prior to every activity. 

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. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
2. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition)
3. 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” in order to participate in any and all activity.

1. Are you currently experiencing any of these symptoms?

• Fever? (Feeling hot to the touch, a temperature of 37.8C or higher)
• Chills
• 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’s 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 the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes.

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

3. 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?
  4. 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 activities.