Human Health Report (Please complete for Agility Spa only)
Updated 10-08-04. Navigate this site using the menu at the top (for sub menu items); or the menu at the bottom (for main menu items). Use your browser's "Back" button to go back to the page you previously viewed.
Please print and mail with your balance of payment (payable to White Mountain Agility) To:
WMA, 431 Chase Road, North Sandwich, New Hampshire 03259.
NOTE: This may not print exactly how it looks - don't worry! Just make sure you complete and send all the pages that your printer spits out!
If you would rather use the pdf forms, please transfer to the "beautiful site" by clicking here, and navigate your camp's registration
forms through the specific camp page. OR, if you would like us to e-mail you a form in Word, just ask! creeksidefarm@sympatico.ca
PLEASE ANSWER ALL QUESTIONS HONESTLY:
Name: ________________________________________________________
E-mail Address: ________________________________________________
Address: _____________________________________________________
City: _____________________________________State: ______Zip Code: _______________
Phone: _________________ Fax #: ____________________Work Phone: ________________
Person to contact in the case of an emergency: ____________________________________
Their phone number: __________________ Their work phone number: _________________
Physician's Name: ______________________________________________
Physician's Phone Number: ______________________ Fax #: ________________________
Your Age: ________ Weight: _________
1. Has your doctor ever said you have heart trouble or any cardiovascular problems?
Yes o No o
2. Do you frequently suffer from pains in your chest? Yes o No o
3. Have you ever suffered from a heart attack? Yes o No o
4. Do you experience an irregular or racing heart rate during exercise or at rest?
Yes o No o
5. Do you often feel faint or have spells of severe dizziness? Yes o No o
6. Has a doctor ever said that your blood pressure is too high? Yes o No o
7. Do you often have difficulty breathing? Yes o No o
8. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to? Yes o No o
9. Are you over age 65 and not accustomed to vigorous exercise? Yes o No o
10. Are you diabetic? Yes o No o
11. Are you pregnant? Yes o No o
If you answered YES to any of the above questions (1 - 11), please note that written physician approval is required prior to attending Agility Spa. This MUST be sent with this form and your balance of payment.
12. List any medications you are now taking and the reason for which they were prescribed: ________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. List any operations you have had (include date): _________________________________________________________________________
_______________________________________________________________________________________________________________________
14. How many times have you visited a physician or any health care professional during the past year? _______
15. How many days did you miss from work last year due to sickness or injury? _________
16. Do you smoke? Yes o No o
17. Indicate how you are coping with daily stress on a scale of 1-10: ________________
18. Indicate your energy level on a scale of 1-10: _______________
19. On the average, how often do you get 7-8 hours of sleep? _________________________
20. How many times per week do you engage in moderate or strenuous exercise for at least 20 minutes? _____________
Describe. _________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
How long have you been doing this? _____________________________________________
21. Have you ever begun an exercise / wellness program and then stopped? Yes o No o
If yes, when? _____________ Why did you stop? _______________________________________________________________________________
__________________________________________________________________________________________________________________________
Thank you very much!
Please note: All personal health information is kept confidential. Please answer all questions honestly - this will help tremendously in case of an emergency.