Health Screening Questionnaire (Brampton Hockey Inc.)

Print Health Screening Questionnaire
This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity.
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  1. Terms and Conditions: Are you currently experiencing any of these issues? Call 911 if you are. You cannot participate in on-ice or off-ice activities. 

    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
  2. Terms and Conditions:

    If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.

    • Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

    • Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder)

    • Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD)

    • 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.
Close Contact - The answer to all questions must be “No” in order to participate in any and all activity (on-ice or off-ice)
For the remaining questions, close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes. Living in the same home
  1. Terms and Conditions: If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-ice or off-ice activities.
Human Validation
Printed from on Monday, October 19, 2020 at 7:48 PM