Health form “QS Sport”

Answer the following questions with YES or NO	YES	NO
1) Did a member of your family die suddenly from a cardiac or unexplained cause?	[__]	[__]
In the last 12 months
2) Have you experienced chest pain, palpitations, unusual shortness of breath or malaise?	[__]	[__]
3) Have you had an episode of wheezing (asthma)?	[__]	[__]
4) Have you had a loss of consciousness?	[__]	[__]
5) If you have stopped sports for 30 days or more due to health reasons, have you resumed without the agreement of a doctor?	[__]	[__]
6) Have you started long-term medical treatment (excluding contraception and allergy desensitization)?	[__]	[__]
To date
7) Do you feel pain, a lack of strength or stiffness following a bone, joint or muscle problem (fracture, sprain, dislocation, tear, tendonitis, etc… ) occurred during the last 12 months?	[__]	[__]
8) Is your sports practice interrupted for health reasons?	[__]	[__]
9) Do you think you need medical advice to continue your sports practice?	[__]	[__]

If answer YES to one or more question(s): consult a doctor to obtain a medical certificate of no contraindication to the practice of hiking in the mountains.