Medical Check Form

Contact Information

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone*

Medical Information

Have you ever been advised by your GP not to exercise?*

Yes
No

Do you have a history of heart problems?*

Yes
No

Do you have high blood pressure/dizziness or lose consciousness?*

Yes
No

Do you have back pain or injury?*

Yes
No

Do you have pain or limited movement in any joints?*

Ankles, knees, hips, etc...

Yes
No

Please Specify:*

Have you been diagnosed with osteopenia or osteoperosis?*

Yes
No

Do you have epilepsy?*

Yes
No

Do you have diabetes?*

Yes
No

Do you smoke?*

Yes
No

Are you pregnant or do you have a child under 6 months?*

Yes
No

Are you taking any prescribed medications?*

Yes
No

Do you know of any other reason why you should not engage in physical activity?*

Yes
No

Please Specify:*

Are you taking any prescribed medications?*

Yes
No

Can you Swim?*

Yes
No

If you have had any surgical proceedurs, injury, chronic illness or other medical condition please give details here:-

Declaration*

I declare that I have answered all the questions on this form honestly and that I have not withheld any pertinent health or medical information.

How Did you Hear About Us?*

Please Specify:*

Consent*

I agree to Booking Terms and Conditions & Privacy Policy.

If you are under 18 your parent or guardian must give permission for you to attend any activity organised by Kayaking.ie. You parent our guardian must also confirm that he/she has accepted our terms and conditions

Parent or Guardian to Tick Box to Confirm Permission and To Confirm Acceptance of our Terms and Conditions and to Verify Medical Informatiom

Name and Contact Number of Parent or Guardian*

Contact Information

Medical Information

UNFORGETTABLE KAYAKING EXPERIENCE

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