Trek Pre Screening Questionnaire

Please fill in the following questionnaire before undertaking any trekking activities:

Please Note:
Trekkers over 70 require a medical certificate form their doctor
Yes No

Emergency Contact Information

Please provide a detailed response of your current weekly exercise activity including time spent on each activity

Medical Conditions

Medical conditions that require a medical certificate from your doctor
Do you currently have and/or have experienced any of the following conditions:

Palpitations / chest pain
Blood Disorder
Heart Condition
Stroke
Diabetes
Dizziness or Fainting
Liver or Kidney conditions
Epilepsy
Cancer (Recent)

Medical conditions that DO NOT require a medical certificate from your doctor
Do you currently have and/or have experienced any of the following conditions:

Low/High Blood Pressure
Gout
Hernia
Stomach/Duodenal Ulcer
Asthma/Breathing condition
Raised Cholesterol
Yes No
Yes No
Yes No

Sport and Physical Injuries

Do you have, or have your had any of the following:

Tendon / ligament damage
Surgery due to injury
Broken or Fractured bones
Back or Neck Pain
Joint Pain
Muscular Pain
Dislocation
Arthritis

Full Disclosure

Do you have any other medical or physical problems or issues we should know about before commencing an exercise program and/ or undertaking your trek?



I have understood the questions above and my answers are true and correct. I have provided full disclosure of any other medical or physical problems or issues that TrekkersAsia Pte Ltd / Amazing Trekkers Club (ATC) should know about before commencing an exercise program and /or undertaking a trek. or I accept that I will not have any claim against ATC or my instructor for any illness, injury or adverse change in medical conditions arising directly or indirectly from any exercise program carried out. I also agree if I do have any changes in my health conditions I will inform ATC and complete this form again. I understand that photographs may be taken and used by ATC for future promotions.
I agree to the terms and conditions *