SayPro Health and Safety Questionnaire Pre-camp health questionnaire to assess fitness levels

SayPro Health and Safety Questionnaire

Pre-Camp Health Questionnaire

This questionnaire is designed to ensure the safety and well-being of all participants. Please answer all questions honestly and accurately. Your responses will help us assess your fitness levels and any medical restrictions to ensure that all activities are safe for you during the camp.

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Participant Information

1. Full Name:
   • First Name: ____________________
   • Last Name: ____________________
2. Date of Birth:
   • MM/DD/YYYY: ____________________
3. Email Address:
4. Phone Number:

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General Health Assessment

5. Do you currently have or have you ever been diagnosed with any of the following conditions?
   (Please check all that apply)
   • ☐ Heart disease
   • ☐ Asthma or respiratory conditions
   • ☐ Diabetes
   • ☐ Epilepsy or seizures
   • ☐ High blood pressure
   • ☐ Back or neck injuries
   • ☐ Joint problems (knees, hips, etc.)
   • ☐ Anxiety, depression, or other mental health conditions
   • ☐ Vertigo or balance issues
   • ☐ Recent surgery (within the past year)
   • ☐ Other: ___________________________
6. Are you currently taking any medications?
   • ☐ Yes
   • ☐ No
     If yes, please list the medications:
7. Do you have any allergies (e.g., food, medication, insect stings)?
   • ☐ Yes
   • ☐ No
     If yes, please specify:
8. Do you have any other medical concerns or conditions that could affect your participation in physical activities?
   • ☐ Yes
   • ☐ No
     If yes, please describe:

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Fitness Assessment

9. How would you rate your overall fitness level?
   • ☐ Sedentary (Little or no physical activity)
   • ☐ Lightly active (Engage in light exercise or walking occasionally)
   • ☐ Moderately active (Engage in moderate exercise or sports 3-4 times a week)
   • ☐ Very active (Engage in intense exercise or sports regularly)
10. Do you participate in regular physical activity (e.g., running, swimming, hiking, gym workouts)?

• ☐ Yes, regularly
• ☐ Yes, occasionally
• ☐ No

11. Have you participated in any extreme sports (e.g., skydiving, bungee jumping, zip-lining, rock climbing)?

• ☐ Yes
• ☐ No
  If yes, please specify which activities and how frequently:

12. Do you have any physical limitations that could affect your ability to engage in extreme sports activities (e.g., chronic pain, limited mobility)?

• ☐ Yes
• ☐ No
  If yes, please describe:

13. Are you able to perform the following basic physical activities without pain or difficulty?
    (Check all that apply)

• ☐ Walking long distances
• ☐ Running
• ☐ Jumping or hopping
• ☐ Climbing stairs
• ☐ Lifting or carrying objects
• ☐ Balance exercises (e.g., standing on one foot)

14. Do you have a history of fainting, dizziness, or lightheadedness during physical activity?

• ☐ Yes
• ☐ No
  If yes, please provide details:

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Mental Health and Readiness

15. Do you feel comfortable with participating in physically challenging and high-risk activities such as bungee jumping, skydiving, or rock climbing?

• ☐ Yes
• ☐ No
  If no, please explain why:

16. Have you ever experienced anxiety, panic attacks, or stress during physical activities?

• ☐ Yes
• ☐ No
  If yes, please describe the circumstances:

17. Are you comfortable in situations where you may feel fear or stress (e.g., before a jump or during a challenging climb)?

• ☐ Yes
• ☐ No
  If no, please provide details:

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Waiver and Acknowledgment

18. By signing below, I acknowledge that I have provided accurate and truthful information about my health, fitness, and medical conditions. I understand that the activities involved in the camp may be physically demanding and may carry inherent risks. I confirm that I am physically and mentally fit to participate in the camp and am aware of any restrictions I may need to take into account during the activities.
19. Signature of Participant:

20. Date:

• MM/DD/YYYY: ____________________

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For Office Use Only:

• Participant Cleared for Activities:
  • ☐ Yes
  • ☐ No
  • Reason for Denial (if applicable): _______________________
• Notes:

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Thank you for completing the health and safety questionnaire! Based on your responses, we will ensure the activities are tailored to your needs and fitness level for a safe and enjoyable experience at the camp.