Medical questionnaire
Preview onlyPlease read the questionnaire carefully before your activity. You do not need to complete it online. We complete the official form together on site.
01
First screeningEveryone starts here
- 1
I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.
Yes — Go to box ANo
- 2
I am over 45 years of age.
Yes — Go to box BNo
- 3
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), or I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.
Yes — Medical evaluation requiredNo
- 4
I have had problems with my eyes, ears, or nasal passages/sinuses or teeth.
Yes — Go to box CNo
- 5
I have had surgery within the last 12 months, or I have ongoing problems related to past surgery.
Yes — Medical evaluation requiredNo
- 6
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. I have a condition where sudden neurological compromise/impairment is possible.
Yes — Go to box DNo
- 7
I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.
Yes — Go to box ENo
- 8
I have had back problems, hernia, ulcers, or diabetes.
Yes — Go to box FNo
- 9
I have had stomach or intestine problems, including recent diarrhea.
Yes — Go to box GNo
- 10
I am currently taking one or more prescription medications. (Note: this need not include birth control, menopausal hormone replacement, and antimalarial medication unless it is mefloquine [Lariam]).
Yes — Medical evaluation requiredNo
02
Further screeningOnly if needed
Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, or am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, or have been diagnosed with emphysema.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.
A YES to any of these questions requires a physician’s medical evaluation.
I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, or have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
A YES to any of these questions requires a physician’s medical evaluation.
Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.
Still healing / recovering from recent dental / oral procedure.
A YES to any of these questions requires a physician’s medical evaluation.
Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease, to include episodic and/or unpredictable loss, reduction, or change in neurological, cognitive, or motor function or performance.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, or take medications to prevent them.
A YES to any of these questions requires a physician’s medical evaluation.
Behavioral health, mental, or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.
An addiction to drugs or alcohol requiring treatment within the last 5 years.
A YES to any of these questions requires a physician’s medical evaluation.
Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either drug or diet controlled, or gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
A YES to any of these questions requires a physician’s medical evaluation.
Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn’s disease.
Bariatric surgery within the last 12 months.
A YES to any of these questions requires a physician’s medical evaluation.
03
Doctor’s clearanceOnly if required
If the questionnaire indicates that medical clearance is required, please arrange it before the activity. A doctor’s visit cannot be arranged on the day. Without required clearance, participation is not possible and no refund is issued.
Version date: 2026-01-01