Booking Form - Rock n Ridge

Booking & Health Form

Please use the form below to fill in your details/information prior to attending your chosen course/activity with us. The form will be only be used by your chosen instructor/s so that they can be informed of any medical information you may have. This will enable them to keep you safe and monitor you as the day goes on. Don’t worry because you may have a medical DOES not mean you will not be able to participate. We prefer to know what’s going on than be kept in the dark. Alternatively if anything changes between now and attending your course, please let your instructor/s know on the day? Thank you for your cooperation and understanding.

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Name

First

Last

Contact Number

Course?

Dates?

Mountain Experience - Leave blank if none

Next of Kin

First

Last

Next of Kin's Number

Medical Questionnaire below:

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Have you ever felt pain in your chest when you do physical exercise?

In the past month, have you had chest pain when you were not doing physical activity?

Do you often feel faint, have spells of severe dizziness or have lost consciousness?

Have you ever suffered from unusual shortness of breath at rest or with mild exertion? Do you often feel faint, have spells of severe dizziness or have lost consciousness?

Has the doctor ever said that you have a bone or joint problem (such as arthritis) that has been aggravated by exercise or that may be made worse by exercise?

Do you have either high or low blood pressure?

Are you currently on any prescribed medicines that may affect your ability to exercise?

Are you pregnant or have you had a baby in the last 6 months?

Have you ever suffered from back pain or had any back-related illness or injury?

If you answered yes to any question, please elaborate. And are there any other medical conditions we should be aware of?

This form and the above medical information will be kept in the strictest confidence and only used by Rock n Ridge/Staff whilst participating in you're chosen activity/s.

Date of Form

Signed - Please Print Name

I have answered honestly and to the best of my knowledge. I agree to update my instructor/s of any medical changes. I agree to take full responsibility of my health during the activity/s including any injuries.