Physical Activity Readiness Questionnaire
Data Protection: This 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.
Name *
Address *
Email *
Phone *
Height *
Choose yes or no to each of the questions below. If you choose ‘yes’ you may need your doctor’s consent before you participate in Nordic Walking.
Has a doctor ever said that you have a heart condition or high blood pressure? *
Do you have chest pain at rest or brought on by physical activity? *
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? *
Do you have a bone or joint problem that could be made worse by physical activity? *
Are you currently taking medication for a condition that you need to carry with you on a walk? *
If you answered "yes" please state your medication here:
Has your doctor ever said that you should only do medically supervised activity? *
Have you been diagnosed with a long term medical condition or allergy that might affect your ability to exercise? *
If yes, please state the conditions or allergies here:
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. The date/time will also be recorded automatically. *
Required
Emergency Contact
Please provide the name and phone number to contact in case of emergency
Emergency Contact Name *
Emergency Contact Phone *
Other Information
Photographs: I give permission to my instructor and British Nordic Walking to use photographs taken of me in publications, advertisements, exhibitions and the internet to illustrate their work and to promote Nordic Walking. This includes use on social media. Due to the nature of the internet, photographs may be shared across numerous channels. The photographs may also be loaned to approved third parties e.g. charitable partners, funders and the media. *
Data Protection: Your email address will be used to notify you about Nordic Walking activities. This 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. *
Where did you hear about Nordic Walking?
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