Health Self-Assessment Questionnaire COVID Self-Assessment This form must be completed before arriving at the Dance Victoria event. "*" indicates required fields • You will be admitted into the building 15 minutes prior to the event • Please be sure to read Dance Victoria's Health Protocols before arrival. The following self-assessment questionnaire is based on the Thrive Health online self-assessment tool which was developed in partnership with the BC Ministry of Health. It is not a diagnostic tool and does not replace the advice of your healthcare provider. For your reference, the original Thrive Health form can be found here.Are you experiencing any of the following:* Severe difficulty breathing Severe chest pain Having a very hard time waking up Feeling confused Losing consciousness None of the above Are you experiencing any of the following:* Mild to moderate shortness of breath Inability to lie down because of difficulty breathing Chronic health conditions that you are having difficulty managing because of difficulty breathing None of the above Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?* Yes No Symptoms include: Fever*, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches. While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discoloration of fingers or toes.Have you travelled outside of Canada within the last 14 days?* Yes No Did you provide care or have close contact with a person with confirmed COVID-19?* Yes No Note: This means you would have been contacted by your health authority’s public health team.Please contact Dance Victoria. Based on your answers, we may not be able to admit you to tomorrow's event. Please email [email protected] or call 250-595-1829First Name* Last Name* Email* Cell Phone** This is necessary in the event that we need to contact you for Coronavirus Contact Tracing purposes.Is there anything else Dance Victoria needs to know?