Pre-Hike Survey
In order to fully support you, please answer honestly. We take your safety and privacy seriously. Responses are only shared with other medical professionals in the event of emergency.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Check any that apply to conditions you are or have experienced:
*
Asthma or Respiratory Conditions
Osteoporosis / low bone density
High or low blood pressure
Cardiac disease
Diabetes
Allergies to pollens
Psychiatric disorder
Allergies to insect stings
Stress-related anxiety
Other
NOT AWARE OF ANY CONDITIONS
Please explain conditions you checked, and how you manage them:
Do you experience any issues with walking, stepping up, stepping down, or mobility in general?
*
Yes
No
Please explain your mobility issues:
Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you have a bone or joint problem (for example, back, knee or hip) that could be made WORSE by a change in your physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you know of ANY OTHER REASON why you should not do physical activity?
*
Yes
No
Please explain the reason you should not do physical activity:
Are you currently taking any prescription medication?
*
Yes
No
Please prescribed medications:
Are you signing for a participant who is under the age of 18?
*
Yes
No
FOR PARTICIPANTS OF MINORITY AGE: Confirm and click/tap to "check" below
*
This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this participant, do confirm that the above statements are complete and accurate.
Please provide an Emergency Contact for you or the Participant
*
First Name
Last Name
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Media Release: Being able to share your story helps us grow! I understand and accept that my image, comments, likeness, accomplishments, goals, and challenges I overcame may be used by Five Miles Further and that I am not entitled to any compensation for such use. I understand I have the right to have the aforementioned remain private by submitting such a request to Five Miles Further by email at fivemilesfurther@gmail.com. I understand that my image and voice may be recorded/captured during calls, online sessions, and in person.
I agree
Signature
*
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