Personal details:

Contact details:


Telephone numbers:

Email Address:

Confidential Questions::

If you answer YES to any of the questions below, you may need your doctors consent before you participate in Nordic Walking. Continuing to participate after answering YES to any of the questions is at your own risk.

Has a doctor ever said that you have a heart condition and recommended only medical supervised activity?

Do you have chest pain brought on by physical activity?

Have you developed chest pain in the last month?

Do you lose consciousness or fall over as a result of dizziness?

Do you have a bone or joint problem that could be aggravated by physical activity?

Has a doctor ever recommended medication for your blood pressure or a heart condition?

Are you aware through your own experience or from a doctors advice of any other reason why you should not exercise without medical supervision?

Please outline any other relevant information that may affect your ability to exercise.

Here existing medical conditions:

Current medication:

Known allergies:

I realise that my bodies reaction to exercise is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my instructor immediately and stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times.

Add signature

Select to see emergency contact details.


Phone number:




Select here if you do not wish to be kept informed of Nordic Walking courses, classes and other events.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.