Tending Soul Fires With Ancestors Confidential Health Questionaire
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Email *
Your Legal Name: 
Please indicate your Emergency Contact:  1) Name, 2) Relationship to them and 3) 1-2 Phone #s to reach them.  If you use a home land line or work phone, include a cell phone or other. *
Secondary Emergency Contact: Please indicate 1) Name, 2) Relationship to them and 3) 1-2 Phone #s to reach them.  If you use a home land line or work phone, include a cell phone or other. *
How would you rate your present degree of physical fitness? *
Is there anything else you feel we should know regarding your physical/emotional condition and history to help us be of better service to you on your program? *
Are you taking any prescribed medications at this time? *
If Yes to question above, please specify the medication and the reason for which it was prescribed.  If no, please indicate N/ *
If you are under the care of a physician or health care provider, do they approve of you engaging in this activity? *
If yes to previous question, please explain.  If no, write N/A *
If you walked on level ground for a mile at an average pace, would you get out of breath, have chest pain or leg pain, or develop muscle fatigue? *
Do you have any disabilities of the back, knees, hips or ankles? *
Have you ever had a lung disease (asthma, emphysema, etc)? *
If yes to previous question, please explain.  If no, write N/A *
Do you have hemophilia? *
If yes to previous question, please explain.  If no, write N/A *
Have you ever experienced a seizure of any kind? *
If yes to previous question, please explain.  If no, write N/A *
Are you hypoglycemic or diabetic? *
Required
Do you have any allergic reactions to any environmental substances, food or drugs? If yes, please list and explain *
Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock? *
If yes, please list and explain *
Do you wear a medic alert bracelet? *
If yes to previous question, please explain.  If no, write N/A *
Are you currently (or within the past two years) receiving treatment from a physician or other health care professional for any physical or psychological reason? *
If yes to previous question, please explain.  If no, write N/A *
Have you ever had a heart attack? *
If yes, please explain. If no, please enter N/A *
Do you have high blood pressure? *
If yes, please list your blood pressure. If no, please enter N/A *
Do you have  a heart murmur or pacemaker? Heart disease? *
If Yes, Please list resting pulse rate if you know it *
When did you last have your tetanus shot? *
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Please check with your insurance company to determine your coverage for this program and bring your insurance identification card or other policy identification with you. WE RESERVE THE RIGHT TO REQUIRE A MEDICAL EXAMINATION OF ANY POTENTIAL PARTICIPANT AT THE PARTICIPANT'S EXPENSE AND TO REJECT ANY POTENTIAL PARTICIPANT FOR MEDICAL OR PSYCHOLOGICAL REASONS AT ANY TIME PRIOR TO OR DURING A PROGRAM.
Confidential Health Questionnaire..... If you wish to sign this form with an electronic signature by typing in your name below and sending it back to us via email, you agree that your electronic signature is your signed acknowledgement that you have read and agree to all of the stipulations listed above and on the next page.Signature *
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