Physical Activity Readiness Questionnaire

Your Details
First Name (required)

Last Name (required)

Email (required)

Date of Birth (required)

Height (required)

Address

Phone Number (required)

Medical Information
Please answer all the following questions. If you answer ‘yes’ to any of them, you may need your doctor’s consent before you participate in Nordic Walking.

1. Has a doctor ever said that you have a heart condition or high blood pressure? —Please choose an option—YesNo

2. Do you have chest pain at rest or brought on by physical activity? —Please choose an option—YesNo

3. Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? —Please choose an option—YesNo

4. Do you have a bone or joint problem that could be made worse by physical activity? —Please choose an option—YesNo

5. Are you currently taking any regular medication? —Please choose an option—YesNo

6. Are you currently taking any medication that you need to carry with you on a walk? —Please choose an option—YesNo

7. Has your doctor ever said that you should only do medically supervised activity? —Please choose an option—YesNo

8. Have you been diagnosed with a long term medical condition or allergy that might affect your ability to exercise? —Please choose an option—YesNo

9. Have you had any major operations in the past? —Please choose an option—YesNo

10. Do you have any problems with your sight or hearing? —Please choose an option—YesNo

Physical Condition
I agree that all the above information is correct and that I have disclosed all relevant medical information. E.g. recent surgery, diabetes, high blood pressure, or ongoing medical treatment. (required)
I realise that my body’s reaction to exercise is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my instructor immediately and stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times. (required)
I am over 80 years old and I have sought consent from my GP to participate in Nordic Walking.

Emergency Contact
Name (required)

Phone Number (required)

In the unlikely event of injury, I am happy for my medical details to be shared with a nominated First Aider / suitably qualified medical practitioners and give permission for medical treatment to be administered where considered necessary by a nominated first aider, or by suitably qualified medical practitioners. (optional)

Photography
Nordic4 would like to sensitively use personal images by photography or video recording for marketing purposes including sharing across social media channels. In the case of video recording, further permission will be asked for at the time.
I give consent to photographs/video being taken of me and used for marketing/social media purposes. (optional)

Data Protection
Your information will be stored securely by the instructor and will not be given to anyone else. You must notify your instructor of any changes in your personal data. Your email address or phone number will be used to notify you about Nordic Walking important changes to sessions, for example, due to weather conditions. This is in accordance with our Privacy Policy.
I agree that my submitted data is being collected and stored. (required)
I would like to hear about future Nordic Walking activities. (optional)

Please tell us how you heard about Nordic Walking