Health Walk Questionnaire - Knowsley Council
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Health Walk Questionnaire
This information will be kept for 'Health Walk' records only
3K walk is both Wheelchair and Push Chair Friendly.
8K walk is not suitable for either of the above.
1. You have the option of participating in either the 2 mile or 5 mile walks, please put a X in the box of your choice.
3K 8K
2. 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
3. Do you feel pain in your chest when you do physical activity?
Yes No
4. In the past month have you had pain in your chest when you were not doing physical activity?
Yes No
5. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes No
6. Do you have diabetes?
Yes No
7. Do you have asthma?
Yes No
I understand that if I answered YES to one or more of the above questions, I should seek medical advice before undertaking a walking programme. I agree to tell the walk leaders if there is a change in my medical condition at any time.
I accept that I/ and/or my children take part in this event at my own risk and that the organisers cannot accept liability, loss or damage as a consequence of my taking part in the Walking Event.
Signed ……………………………………………… Name (please print)………………………………..
Date…………………………… E-Mai……………………………………TelNumber………………….. ..
Home address………………………………………………………………………………………………….
Post Code……….
There will some photographs taken of the walk to publicise future walks. Please indicate if you consent or not below (please tick)
I give permission to use photos I do not give permission to use photos
Please send your completed form to
Steve Guy
Sports Development office
Huyton Leisure Centre
Roby road
Huyton
Knowsley
L36 4HA
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If you have decided to increase the amount of physical activity in your life, start by answering the seven questions below. For most people physical activity should not pose any problem or hazard, but this Health Walk Questionnaire has been designed to identify the small number of people for whom it would be wise to have medical advice before starting.
PLEASE ADVISE THE WALK LEADER OF ANY OTHER CONDITTIONS YOU FEEL THEY MIGHT NEED TO KNOW ABOUT
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