Outdoor Health Questionnaire

Name of scheme FitSteps Health Walks FitSteps Country Walks

A. Participant Details

Title Mr Mrs Miss Ms First name Surname

Address
Postcode

Telephone No Mobile No

E-mail

Please provide the name and telephone number of someone who can be contacted in
emergency


B. Health Screening
For most people, physical activity does not pose a hazard. The questions below have
been designed to identify the small number of prople for whom it would be wise to have
medical advice before starting.

1. Has your doctor ever said that you have a heart condition ? Yes No
2. Do you feel pain in your chest when active ? Yes No
3. Do you ever lose balance/consciousness ? Yes No
4. Do you feel pain in your chest when resting? Yes No
5. Do you have a bone/joint condition ? Yes No

Declaration
I understand that if I have answered 'Yes' to one or more of the above questions, I
should seek medical advice before attending a walking programme. I agree to tell the
walk leaders if there is a change in my medical condition. I understand that this
information will be shared with other walk leaders and that I walk at my own risk.

Signed/Name Date

To make the case for funding for your walking schemes, please help us by answering
the following questions:

6. Have you been diagnosed by your doctor or health professional with any of the
five medical conditions ?

Heart Disease Yes No
High Blood Pressure Yes No
COPD (Emphysema and Chronic Bronchitis) Yes No
Diabetes Yes No
Asthma Yes No

7. Do you have a long-standing (ie. for more than 12 months and likely to continue)
illness or disability which affects (or limits) your day to day activities?

Yes No Prefer not to say

If yes, please give brief details:


Please advise the walk leader if you have any other conditions you feel
they might need to know of.

C. About You

1. New Walker Existing Walker Returning Walker (not walked 3+months)

2. Are you a trained volunteer walk leader ? Yes No

3. Have you been recommended by your doctor or health professional to come on
this scheme ? Yes No

4. In the past week, on how many days have you accumulated at least 30 minutes
of moderate physical activity such as brisk walking, cycling, sport, exercise and
active recreation ? (Do not include physical activity that may be part of your job or
usual role activities.)

Number of days 0 1 2 3 4 5 6 7

Because WHI is a public service, we have to report the following information to the
Office of National Statistics. Please help us !

5. Age group 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ 5a. D.O.B. 6. Gender Male Female

7. Ethnicity White/British White/Irish White/Other Mixed/White&Black Caribbean Mixed/White&Black African Mixed/White&Asian Mixed/Other Mixed Asian or Asian British/Indian Asian or Asian British/Pakistani Asian or Asian British/Bangladeshi Asian or Asian British/Other Asian Black or Black British/Caribbean Black or Black British/African Black or Black British/Other Black Chinese or other ethnic group/Chinese Chinese or other ethnic group/Other Other (please specify)

8. Thank you for completing this questionnaire. Are you happy to be contacted to
helpus evaluate health walks ? Yes No

Using and sharing your information
Your information will be held by Natural England, in accordance with the Data
Protection Act 1998. It will be used by each local scheme to evaluate their health
walks and show funders that they offer value for money. Summary information
will also be used by Natural England to further its work on safeguarding and
promoting the use of the natural environment to improve the health of the
population. The information will be collected by walk leaders and passed on to
walk co-ordinators for inputting into a central database. This will be used to draw
anonymous reports for both the local scheme and the national programme. The
result of any analysis will be used to influence and support further funding bids
for the local and national schemes and help define the health value of the
natural environment.

I have read and understood the above statement

Signed/Name Date

Where did you hear about Fitsteps ? GP/health professional referral School/college Youth group Walking group Poster/advertisement Leisure Centre Resident's Association Other(please state which)