COVID-19 FORM | Gold's Gym Calgary

Are you completing this assessment for a child/youth? *Child/youth refers to individuals under 18, as well as individuals attending high school who are 18 or older.

Yes

No

Are you experiencing any of the followig:

Are you experiencing any of the following:

Shortness of breath at rest

Inability to lie down because of difficulty breathing

Chronic health conditions that you are having difficulty managing because of your current respiratory illness

No

In the past 10 days, have you experienced any of the following:

Do you have any of the following:

In the past 14 days, were you notified that you are connected to an outbreak OR that you are close contact of a confirmed case of COVID-19 by:

Yes

No

In the past 14 days, did you return from travel outside of Canada?

Yes

No

Do you require testing for the purpose of outgoing travel?

Yes

No

Take steps to protect yourself and others.

All Albertans have a responsibility to help prevent the spread of COVID-19. There are steps you can take to protect yourself and others.

Practice physical distancing. This is not the same as self-isolation. You do not need to remain indoors, but you do need to avoid being in close contact with people.

Practice good hygiene: wash your hands often, cover coughs and sneezes and avoid touching your face.

If you do develop any COVID-19 symptoms, stay home and take this self-assessment again.

By signing this you are a verifying that all the information is true

Daily Client COVID-19 Assessment