Way of Nature Program Participation
Health Questionnaire
Below are the questions that we ask you to answer before participating in a Way of Nature retreat. By providing this information, you are informing us of any potential health complications that could effect your ability to participate, therefore helping us to ensure your safety during the course of the retreat. We hold your health and privacy sacred, and will not share this information with anyone except for medical professionals in the case of an emergency.
CONFIDENTIAL HEALTH QUESTIONNAIRE
Name:__________________________________________________________________
Address:________________________________________________________________
_______________________________________________________________________
Emergency Phone Contact:(__________) _____________-__________________
The following questions are designed to provide our guides with as much information regarding your health and wellness as possible to support a safe experience for all.
General Fitness
1) If you were to walk on level ground for a mile at an average pace, would you experience any shortness of breath, chest pains, develop muscle fatigue, or have any pains in your legs?
Yes_____ No_____
2) Do you have any physical challenges that would make moderate exercise difficult or impossible?
Yes_____ No_____
If yes, please specify:________________________________________________________________
_______________________________________________________________________
3) Do you have any disabilities of the back, hips, knees or ankles?
Yes_____ No_____
4) Do you wear a Medic-Alert Tag? Yes_____ No_____
5) Are there any reasons why you should not fast? Yes_____ No_____
General Background
1) Do you have hypoglycemia? Yes_____ No_____
2) Do you experience allergic reactions to any foods, drugs, or environmental substances?
Yes_____ No_____
If yes, please specify:_________________________________________________________________
________________________________________________________________________
3) Do you have asthma? Yes_____ No_____
4) Do you experience anaphylactic shock from bee stings?
Yes_____ No_____
5) Do you have any heart problems diagnosed by a physician?
High Blood Pressure? Yes_____ No_____
Low Blood Pressure? Yes_____ No_____
Heart Murmur? Yes_____ No_____ Other_____
If other, please specify:________________________________________________________________
6) Do you have hemophilia? Yes_____ No_____
7) Have you ever had lung disease? Yes_____ No_____
8) Have you ever experienced a seizure of any kind? Yes_____ No_____
9) Have you ever had psychological or psychiatric treatment?
Yes_____ No_____
If yes, please specify:_________________________________________________________________
________________________________________________________________________
10) Are you currently experiencing any health or emotional imbalances that would interfere with this activity?
Yes_____ No_____
If yes, please specify:_________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Dated this________day of______________________, ___________(year)
______________________________________
Participant Signature
______________________________________
Legal Guardian Signature (if applicable)