COVID-19 Self-Screening

Each week, all members, currently playing squash in a Squash Bubble, must complete the following form.

If you answer "Yes" to any of the questions below, please do not come to the Racquet Club.

Stay home if you are self isolating or contact Public Health if you are feeling ill.

Member's First and Last Name *

Today's Date *

Month

Day

Year

Email *

Have you, or anyone in your household traveled outside of the NWT in the past 14 days? *

Yes

Are you currently in self-isolation due to travel? *

Yes

Have you, or anyone in your household, been in contact in the last 14 days with someone that is being investigated for or confirmed to have COVID-19? *

Yes

Have you, or anyone in your household, been instructed to self-isolate? *

Yes

Do you have any ONE of the following symptoms? *

1. Fever
2. New or worsening cough
3. Shortness of breath

Yes

Do you have TWO or more of any of the following symptoms? *

1. Sore throat
2. Runny nose
3. Nausea/vomiting
4. Diarrhea
5. Headache
6. Feeling generally run down or tired
7. New loss or decrease in sense of smell or taste
8. Body aches

Yes

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Tel 867.920.2224 • Fax 867.920.2480 • 4002-49th Avenue • Yellowknife, Northwest Territories X1A 2N4 CANADA