Medical Form

Please complete the form below as accurately as you can.

We will use the information you provide to assess whether you are physically able to complete the walk. Please note that a YES answer does NOT mean that you are unsuitable to do the walk...we require a basic level of fitness and health...you do not need to be an Olympic athelete!

First Name:
Surname:
Street:
Town/Suburb:
State:
Postcode:
Country:
Contact Telephone:
Email Address:
Height in cm:
Weight in kg:
Age:
Sex: Male
Female
Do you currently have OR have a history of: Respiratory problems or Asthma
Diabetes
Hytertension
Bleeding or blood disorders
Neurological problems or Epilepsy
Seizures
Dizziness or fainting episodes
Are you pregnant
Do you have any other heath complaint that we should know about?:
Do you have any Cardiac problems?: Yes
No
Have you every had any form of heart implant device such as valve or ASD closure?: Yes
No
Do you currently have OR a history of: High blood pressure
Cardiovascular disease
High blood cholesterol
Obesity
Smoking more than 1 pack per day
Family history of cardiac disease
Unexplained chest pain
Shortness of breath
Palpitations
Do you currently have or have a history of: Knee injury
Hip injury
Shoulder injury
Arm injury
Back injury
Ankle injury (inc. sprains)
If you checked any of the boxes in the above question, please explain details & date of injury:
Are you allergic to: Insect bite
Bee sting
Are you allergic to any medications?: Yes
No
Have you ever had frostbite?: Yes
No
Have you ever had Acute Mountain Sickness [Altitude sickness]?: Yes
No
Have you ever had heat stroke or a heat related illness?: Yes
No
Which of the following activities have you undertaken in the past 3 months?: Cycling
Walking
Walking Stairs
Swimming
Sailing
Tennis
Running
Gymnasium
Cross Country Skiing
Downhill Skiing
Rock Climbing
Jogging
Aerobics
Football
Gardening
Golf
When you exercise, what is the intensity?: Easy
Moderate
Competitive
How would you best describe your level of physical activity?:
With regards to hiking, bush walking or tramping, which of the following statements would best describe you:
What would be the greatest distance you have walked or run in a single day in the past year?
Do you smoke?:
Have you had a Tetanus immunisation in the past 10 years?: Yes
No
I have read the DISCLOSURE STATEMENT prior to completing this form and advise that information provided is true and correct: YES
No

A joint project of Mt Baw Baw Alpine Resort & Walhalla's Star Hotel    © Michael Leaney 2010