Great Walhalla Alpine Trail

Mt Baw Baw to Walhalla

Medical Form

Please complete the form below as accurately as you can.

We will use the information you provide to assess whether you are physically able to complete the walk. Please note that a YES answer does NOT mean that you are unsuitable to do the walk...we require a basic level of fitness and health...you do not need to be an Olympic athelete!

First Name:
Surname:
Street:
Town/Suburb:
State:
Postcode:
Country:
Contact Telephone:
Email Address:
Height in cm:
Weight in kg:
Age:
Sex:	Male Female
Do you currently have OR have a history of:	Respiratory problems or Asthma Diabetes Hytertension Bleeding or blood disorders Neurological problems or Epilepsy Seizures Dizziness or fainting episodes Are you pregnant
Do you have any other heath complaint that we should know about?:
Do you have any Cardiac problems?:	Yes No
Have you every had any form of heart implant device such as valve or ASD closure?:	Yes No
Do you currently have OR a history of:	High blood pressure Cardiovascular disease High blood cholesterol Obesity Smoking more than 1 pack per day Family history of cardiac disease Unexplained chest pain Shortness of breath Palpitations
Do you currently have or have a history of:	Knee injury Hip injury Shoulder injury Arm injury Back injury Ankle injury (inc. sprains)
If you checked any of the boxes in the above question, please explain details & date of injury:
Are you allergic to:	Insect bite Bee sting
Are you allergic to any medications?:	Yes No
Have you ever had frostbite?:	Yes No
Have you ever had Acute Mountain Sickness [Altitude sickness]?:	Yes No
Have you ever had heat stroke or a heat related illness?:	Yes No
Which of the following activities have you undertaken in the past 3 months?:	Cycling Walking Walking Stairs Swimming Sailing Tennis Running Gymnasium Cross Country Skiing Downhill Skiing Rock Climbing Jogging Aerobics Football Gardening Golf
When you exercise, what is the intensity?:	Easy Moderate Competitive
How would you best describe your level of physical activity?:
With regards to hiking, bush walking or tramping, which of the following statements would best describe you:
What would be the greatest distance you have walked or run in a single day in the past year?
Do you smoke?:
Have you had a Tetanus immunisation in the past 10 years?:	Yes No
I have read the DISCLOSURE STATEMENT prior to completing this form and advise that information provided is true and correct:	YES No

Great Walhalla Alpine Trail

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Medical Form