Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
Email Address
*
Date of birth
*
Please enter in MM DD YYYY format
MM
DD
YYYY
Emergency contact number
*
Please give the name of your emergancy contact.
*
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by your doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you have not been doing physical activity?
*
Yes
No
Do you lose balance because of dizziness or do you lose consciousness?
*
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing medication for your blood pressure or a heart condition?
*
Yes
No
Do you know of any other reason why you should not take part in physical activity?
*
Yes
No
If yes, please comment:
Are you currently taking any medication?
*
YES
NO
If yes, please give details below.
Have you ever been pregnant?
*
Yes, I am pregnant now
Yes
No
If Yes, please give details of any complications during pregnancy or after, type of delivery, any other important information. Small details can make a big difference to your diet and exercise capabilities so please include any concerns, no matter how small.
Please confirm you have purchased your own travel insurance covering the dates we are on the retreat.
*
I CONFIRM AND AGREE
NO
If you have recently given birth please confirm that you have had your 6-10 week post natal Midwife/ GP medical check up and they have agreed you are able to take part in physical activity
*
I CONFIRM AND AGREE
I DO NOT CONFIRM AND I DISAGREE
N/A
Please confirm that you have read, understood and accurately completed this questionnaire. That you are voluntarily engaging in an acceptable level of exercise, and you understand that your participation involves risk of injury.
*
I CONFIRM AND AGREE