CONFIDENTIAL QUESTIONNAIRE

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. Please be assured that these forms are confidential and will only be shared with and used by the retreat and excursion guides.

Name *
Name
Date of Birth *
Date of Birth
Home Address *
Home Address
Phone *
Phone
Outdoors
Have you ever spent a full day (or longer) in the wilderness? *
Have you gone overnight camping in the wilderness? *
How would you rate your comfort level in the wilderness? *
Fitness
If you were to walk on level ground for 1 mile or 2 kilometers at an average pace, would you experience any shortness of breath, chest pains, develop muscle fatigue, or have any pains in your legs? *
When it comes to hilly terrain, what type of hiker would you consider yourself? *
Do you have any physical challenges that would make moderate exercise difficult or impossible? *
If you are under the care of a physician, does he/she approve of you engaging in this activity? *
Medical
Do you wear a Medic Alert Bracelet? *
Do you have any heart problems diagnosed by a physician? *
Have you ever had a heart attack? *
Are you hypoglycemic or diabetic? *
Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock? *
Do you have any allergic reactions to any environmental substances, food or drugs? *
Do you have any dietary restrictions? *
Have you ever experienced a seizure of any kind? *
Do you have hemophilia? *
Do you have any disabilities of the back, knees, hips or ankles? *
Have you ever had a lung disease? *
(asthma, emphysema, etc.)
(year)
Are you currently experiencing any health or emotional imbalances that would interfere with this activity? *
Are you taking any prescribed medications at this time? *
Is there anything else you feel we should know regarding your physical/emotional condition and/or history to help us be of better service to you during the retreat? *
Signature
Electronic Signature of Participant *
Electronic Signature of Participant
Date *
Date
Emergency Contact Information During the Retreat or Excursion
Please be specific (include all country codes).
Primary Contact Person *
Primary Contact Person
Home Phone *
Home Phone
Mobile Phone *
Mobile Phone