COVID-19 Self-Assessment

Thank you for your support of the Huntington Society of Canada (HSC) and our mission to improve the lives of everyone affected by Huntington disease. Completion of this health questionnaire is required for health and safety purposes (that is, for purposes of reducing the risk of spreading COVID-19 and protecting our community).

Please know that HSC will:

not use or disclose this information for any other purpose,
maintain the privacy and security of this information, including taking precautions to avoid any unauthorized access to or use or disclosure of this information.

If you have any questions, please contact us at events@huntingtonsociety.ca.

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* 1. Please enter the following information:

City/Town

State/Province

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* 2. Which Event are you Attending?

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* 3. In the past 5 days, have you been diagnosed with COVID-19 or have you tested positive for COVID-19?

Yes

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* 4. Are you currently experiencing, or have you experienced in the past 5 days, any of the following symptoms of COVID-19? Please check all that apply.

Fever or chills

Cough

Shortness of breath

Decreased or loss of taste or smell

Runny nose or nasal congestion

Headache

Feeling unwell, fatigue or severe exhaustion

Painful swallowing

Muscle aches or joint pain

Nausea, vomiting, diarrhea or unexplained loss of appetite

Conjunctivitis (pink eye)

None of the Above

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* 5. Do you feel well overall?

Yes