WildBridge Tours Medical and Physical Fitness Screening Form

Participant Information

Full Name

Preferred Name

Date of Birth

Phone Number

Email Address

Emergency Contact

Emergency Contact Name

Relationship to Emergency Contact:

Emergency Contact Phone

Medical History

In most cases, informing us of medical concerns does not prevent your participation in the trip but it will help us be best prepared to help you enjoy your time!

If you choose not to inform us of a medical condition that we feel may affect your safety or the group’s safety the lead guide has the authority to deny your participation even after the trip has begun.

Do you live with any medical conditions? (diabetes, heart disease, asthma, etc.)

Yes

If yes, please specify:

Have you been hospitalized or undergone surgery in the past five years?

Yes

If yes, please specify:

Do you have any allergies (medications, food, environmental, etc.)?

Yes

If yes, please list:

What happens if you’re exposed?

Do you take any medications regularly?

Yes

If yes, please list name, dosage, and purpose:

Do you have a history of heart problems, high blood pressure, or chest pain?

Yes

If yes, please describe:

Have you ever experienced dizziness, fainting, or shortness of breath during physical activity?

Yes

If yes, please explain:

Have you been diagnosed with a bone, joint, or muscular condition that could be aggravated by physical activity?

Yes

If yes, please provide details:

Have you had a tetanus immunization within the last 10 years?

Yes

Please provide the date of your most recent tetanus immunization (must be within 10 years)

If not within the last ten years please inform WildBridge Tours as soon as you have updated your immunization.

Fears & Concerns

Do you have any specific fears or phobias? (heights, water, insects etc.)

Yes

If yes, please specify:

Are there any other personal concerns or anxieties you would like us to be aware of?

Yes

If yes, please describe:

Psychological & Emotional Well-being

Do you live with any psychological challenges? (anxiety, depression, PTSD, etc.)

Yes

If yes, please specify:

Do you experience stress, panic attacks, or emotional distress that might be triggered by certain environments or activities?

Yes

If yes, please specify:

What strategies or practices help you manage stress and maintain emotional well-being? (This question is for everyone!)

Emergency Information & Consent

In case of an emergency, do you authorize our guides to provide first aid and to arrange for appropriate emergency medical treatment?

Yes

Do you have appropriate medical and trip interuption/cancellation insurance?

Yes

Insurance Provider:

Policy Number:

Physical Fitness Assessment

How often do you engage in physical activity?

Rarely / Never

1-2 times per week

3-4 times per week

5+ times per week

What types of physical activities do you regularly participate in?

What other activities:

Do you experience pain or discomfort during physical activity?

Yes

If yes, please explain:

Do you have any restrictions or limitations that may impact your ability to participate in physical activities?

Yes

If yes, please specify:

Do you have any concerns about your balance?

Yes

If yes, please describe:

Are you working with a personal trainer, physical therapist, or coach for fitness or rehabilitation purposes?

Yes

If yes, please describe:

Participant Acknowledgment & Signature

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that participating in physical activities involves risks and I assume full responsibility for my health and well-being. If my medical condition changes, I will notify WildBridge Tours as soon as possible.

Please use the following space to add any additional information we should know: