Older Adults COVID-19 Screening Tool

Note: This tool must be filled out no earlier than 2 hours prior to your visit.

Please complete all questions and submit your results. Once submitted, an email will be sent to the email address provided in the tool below. Proof of completing this tool must be shown prior to entering the facility. Thank you for your co-operation.

Are you currently, or have you in the past 24 hours, been feeling unwell OR do you have any new unexplained symptoms related to COVID-19:

  • Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius 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 (not related to seasonal allergies or other known causes or conditions)
  • Stuffy or congested nose (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 young children and infants: sluggishness or lack of appetite


I understand that if I do not pass this screening tool I am not to enter the facility.

I understand that if I become ill or develop symptoms while in the facility, I should leave the facility immediately, self-isolate and contact Public Health for information regarding COVID-19 testing.

Any collection of personal information is made under the authority of the Ministry of Health COVID-19 Guidance for facilities for sports and recreational fitness activities during COVID-19. Personal information is collected in compliance with the Municipal Freedom of Information and Protection of Privacy Act.

Personal information is collected for the purpose of complying with provincial orders related to the COVID-19 pandemic.  None of your personal information will be shared, rented, sold or otherwise released to any third party without your consent. 

Any questions about this collection should be directed to: 625-2351.

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