Covid 19 Self Assessment - Dragon Taekwondo Academy Milton

Are you currently experiencing any of these issues? Call 911 if you are. Severe difficulty breathing (struggling for each breath, can only speak in single words) Severe chest pain (constant tightness or crushing sensation) Feeling confused or unsure of where you are Losing consciousness*

Yes No

How old are you? We collect this anonymous information to better understand how the virus affects different age groups.*

What are the first 3 characters of your postal code? Help us locate where the virus is potentially spreading by providing this anonymous information. The first 3 characters only tell us your general area and not your street name or number.*

Are you currently experiencing any of these symptoms? Choose any/all that are new and not related to seasonal allergies or pre-existing medical conditions.*

Receiving treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors). Have a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder). Have 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)*

Yes No

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19? Close physical contact means being less than 2 metres away in the same room, workspace, or area living in the same home*

Yes No

In the last 14 days, have you been in close physical contact with someone who either: • Is currently sick with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)? • Returned from outside of Canada in the last 2 weeks with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)? Close physical contact means being less than 2 metres away in the same room, workspace, or area living in the same home*

Yes No

Have you travelled outside of Canada in the last 14 days? This does not include essential workers who cross the Canada-US border regularly.*

Yes No

COVID-19 Self-assessment

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