Health Questionnaire

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have high blood pressure? *

Yes

No

Have you had a heart attack? *

Yes

No

If so, when?

MM

DD

YYYY

Do you have a heart murmur? *

Yes

No

Do you have heart disease? *

Yes

No

Do you wear a medical alert bracelet? *

Yes

No

Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock? *

Yes

No

Do you have any allergic reaction to environmental substances, foods, or drugs? *

Yes

No

Are you hypoglycemic or diabetic? *

Yes

No

Have you ever experienced a siezure of any kind? *

Yes

No

Do you have hemophilia? *

Yes

No

Have you ever had a lung disease, asthma, emphysema, COPD? *

Yes

No

If you walked on the level for a mile at an average pace, would you get out of breath, chest pain or leg pain, or develop muscle fatique? *

Yes

No

If you are under the care of a physician does he/she approve of your participation in this activity? *

Yes

No

When did you have your last tetanus shot? *

If you do not know or have never received a tetanus vaccination, enter 01/01/2000.

MM

DD

YYYY

Are you currently (or within the past 2 years) receiving treatment from a physician or other health care professional for any physical or psychological reason? *

Yes

No

Are you taking any prescribed medications at this time? *

Yes

No

Terms & Conditions *

I have read and understand the Wilderness Dance Health Questionnaire and have answered the questions to the best of my knowledge.

Agree