This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice
activity. This questionnaire may be completed verbally.
Are you currently experiencing any of these issues? Call 911 if you are.
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
This form MUST be completed THE DAY OF scheduled PGHA activity. If symptoms change after you have completed this form please update.
You are required to show confirmation of completing this form to a PGHA representative prior to participating in the scheduled activity.