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)