Please print out, complete, and bring along with you to the walk.
Health Walk Questionnaire
Becoming more active is very safe for most people. Some people should check with their doctor before they start becoming much more physically active. Start by answering the all of the questions below.
1. Has your doctor ever said that you have a heart condition? | Yes c No c |
2. Do you feel pain in your chest when you do physical activity? | Yes c No c |
3. In the past month, have you had chest pain when you were not doing physical activity? | Yes c No c |
4. Do you lose your balance because of dizziness or do you ever lose consciousness? | Yes c No c |
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? | Yes c No c |
Declaration
· I understand that if I have answered ‘Yes’ to one or more of the above questions, I should seek medical advice before attending a walking programme and that I walk at my own risk.
· I agree to tell the walk leaders if there are any changes in my health which affect my answers to the above questions.
· I understand that this information will be shared with other walk leaders.
Name (print):
……………………………………………………………………………………………
……………………………………………………………………………………………
Signed:
…………………………………………………………………………………………….
…………………………………………………………………………………………….
Date: …………………………………………………………………………………………….
6. Do you have diabetes? Yes c No c
7. Do you have asthma? Yes c No c
8. Do you have a long-standing illness or disability which affects or limits your day to day activities? Yes c No c
If yes, please give brief details: …………………………………………………………………………………
……………………………………………………………………………………………………………………
Please advise the Walk Leader of any other conditions you feel they might need to know about.
Emergency contact details Name: ……………………………………………………………………………………………….... Tel no: ………………………………………………………………………………………………… |
