SayPro Health and Safety Questionnaire Template: A health questionnaire to assess fitness levels and potential risks.

Here’s a SayPro Health and Safety Questionnaire Template to assess fitness levels and potential risks for participants before they engage in extreme sports activities:

SayPro Health and Safety Questionnaire

Participant Information:

1. Full Name:
   • (First Name, Last Name)
2. Date of Birth:
   • (MM/DD/YYYY)

Health History:

3. Do you have any current or past medical conditions?
   • (Yes / No)
     If yes, please provide details:
   • (Text Box)
4. Do you have any allergies (e.g., food, medications, environmental)?
   • (Yes / No)
     If yes, please list them:
   • (Text Box)
5. Do you take any prescribed or over-the-counter medications?
   • (Yes / No)
     If yes, please provide the name(s) of the medication(s):
   • (Text Box)
6. Have you ever had surgery or been hospitalized?
   • (Yes / No)
     If yes, please provide details:
   • (Text Box)

Physical Fitness Assessment:

7. How would you rate your current fitness level?
   • (Low / Moderate / High)
8. Do you engage in regular physical activity (e.g., exercise, sports)?
   • (Yes / No)
     If yes, what type of activities do you participate in?
   • (Text Box)
9. Do you have any issues with mobility, balance, or coordination?
   • (Yes / No)
     If yes, please provide details:
   • (Text Box)
10. Do you experience any of the following (check all that apply):

• Chest pain or discomfort
• Shortness of breath
• Dizziness or fainting
• Frequent headaches
• Nausea
• (Check all that apply)

Medical Clearance:

11. Has a doctor ever advised you to avoid intense physical activities or extreme sports?

• (Yes / No)
  If yes, please explain:
• (Text Box)

12. Do you have any heart conditions or respiratory issues?

• (Yes / No)
  If yes, please provide details:
• (Text Box)

13. Do you have any joint, muscle, or skeletal issues (e.g., back, knee, ankle problems)?

• (Yes / No)
  If yes, please explain:
• (Text Box)

14. Do you suffer from any mental health conditions that may affect your participation (e.g., anxiety, PTSD, panic attacks)?

• (Yes / No)
  If yes, please provide details:
• (Text Box)

Extreme Sports Participation Risk Acknowledgment:

15. Do you acknowledge the risks involved in participating in extreme sports activities, and do you confirm that you are physically and mentally prepared for these activities?

• (Yes / No)

16. Do you have any concerns or conditions that could impact your ability to safely participate in activities such as bungee jumping, skydiving, or zip-lining?

• (Yes / No)
  If yes, please specify:
• (Text Box)

Emergency Contact Information:

17. Emergency Contact Name:

• (Full Name)

18. Relationship to Participant:

• (e.g., Parent, Spouse, Friend)

19. Emergency Contact Phone Number:

• (Mobile Number)

By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that I must notify SayPro staff of any changes to my health or medical status prior to the camp.

Submit Questionnaire:

• (Button)

This questionnaire is designed to gather detailed health information to ensure that participants are fit to take part in extreme sports activities and that any risks are carefully assessed and managed. The medical clearance section helps confirm that participants are prepared for the physical demands of the camp while prioritizing their safety.