SayPro Health and Safety Questionnaire: Pre-camp health questionnaire to assess fitness levels and any medical restrictions.

Here’s a SayPro Health and Safety Questionnaire designed to assess participants’ fitness levels, identify medical restrictions, and ensure their safety before engaging in extreme sports activities:

SayPro Health and Safety Questionnaire: Pre-Camp

Participant Information:

1. Full Name:
   (First Name, Last Name)
2. Date of Birth:
   (MM/DD/YYYY)
3. Emergency Contact Name:
   (First Name, Last Name)
4. Emergency Contact Phone Number:
   (Mobile Number)

General Health Information:

1. Do you currently have or have you had any of the following conditions? (Check all that apply)
   • Asthma or breathing issues
   • Heart conditions (e.g., heart attack, heart disease, arrhythmia)
   • High blood pressure
   • Seizures
   • Diabetes (Type 1 or Type 2)
   • Back or neck problems
   • Joint or bone issues (e.g., arthritis, fractures)
   • Dizziness, fainting, or blackouts
   • Severe allergies (please specify below)
   • Recent surgery or injury (within the last 6 months)
   • Other (Please specify): ____________________________
2. Do you take any medication(s)?
   • Yes
   • No
     If yes, please list them:
3. Do you have any known allergies (food, medication, insect bites, etc.)?
   • Yes
   • No
     If yes, please list:
4. Are you pregnant or do you have a pregnancy-related condition?
   • Yes
   • No

Fitness and Activity Readiness:

5. How would you rate your overall fitness level?
   • Excellent
   • Good
   • Fair
   • Poor
6. Have you participated in extreme sports or high-adrenaline activities (e.g., skydiving, bungee jumping, zip-lining) before?
   • Yes
   • No
7. Do you currently engage in regular physical activity (e.g., jogging, sports, exercise)?
   • Yes
   • No
     If yes, please describe the type of activity:
8. Do you have any of the following concerns or restrictions regarding physical activities?
   • Chronic pain or discomfort
   • Difficulty with balance or coordination
   • Shortness of breath or chest pain with exertion
   • History of dislocations, fractures, or other bone injuries
   • Other concerns (Please specify): _______________________

Medical Authorization and Acknowledgment:

9. Do you have any other health conditions or medical information that might affect your participation in extreme sports activities?
   • Yes
   • No
     If yes, please specify:
10. Have you been cleared by a healthcare provider to participate in physically demanding activities, including extreme sports?

• Yes
• No
  If no, please explain:

11. Do you consent to receiving medical treatment in the event of an emergency during camp activities?

• Yes
• No

Waiver and Agreement:

12. I acknowledge that extreme sports involve inherent risks, and I understand the need to follow all safety protocols and instructions to minimize the risk of injury. By completing this questionnaire, I confirm that I have provided accurate information to the best of my knowledge and am fit to participate in the planned activities.

• I agree to the terms and confirm that the information provided is accurate.

Participant’s Signature:
(Participant’s signature or typed name for consent)

Date:
(MM/DD/YYYY)

For Participants Under 18 Years of Age:

A parent or guardian must complete the Health and Safety Questionnaire on behalf of the participant.

This questionnaire captures key health-related details to ensure all participants are medically fit for the planned extreme sports activities and have appropriate safety measures in place. It also provides an opportunity for participants to disclose any pre-existing conditions or concerns that may need attention.