We want to make sure our walking programmes help everyone become more active. These questions will help us know a bit more about you, and, the information could help us get funding for future walking programmes. We won't pass on your personal details to any other organisations.

1. Forename *
   
2. Surname *
   
3. Gender
     Male   Female This field is required
4. Phone *
   
5. Address Line 1 *
   
6. Address Line 2
   
7. Town *
   
8. County
   
9. Postcode (England only) *
   
10. E mail *
    
11. Age *
    Under 16 16-24 25-34 35-44 45-54 55-64 65 or over
12. How would you describe your ethnic origin?*
    White British White Irish White Other Black or Black British / African Mixed Race Black or Black British / Caribbean Asian or Asian British / Indian Asian or Asian British / Bangladeshi Asian or Asian British / Pakistani Asian or Asian British / Other Chinese Other
13. If “Other”, please describe here
    

Most people can start walking with no risk to their health. However, all walkers walk at their own risk. Please answer the questions below by selecting yes or no.

1. Has your doctor ever said you have a heart condition?
     Yes  No This field is required
2. Do you feel pain in your chest when you do physical activity?
    Yes  No This field is required
3. In the past month have you have pain in your chest when you were NOT doing physical activity?
    Yes  No This field is required
4. Do you have a bone or joint condition that could be made worse by a change in your physical activity?
    Yes  No This field is required
5. Do you ever lose balance because of dizziness or ever lose consciousness?
    Yes  No This field is required
6. I understand that if I answered YES to one or more of the above questions, I should seek medical advice before increasing my walking.
    I agree This field is required
7. I understand that I walk at my own risk
     This field is required

We want to make sure our walking programmes help everyone become more active. We’d like to know how active you are at the moment.

Brisk activity

1. In the past week, how many days did you do a minimum of 30 minutes’ activity which was enough to make you breathe faster? (Activities may include sport, exercise, brisk walking or cycling but NOT housework or physical activity that is part of your job.) * *
   0 1 2 3 4 5 6 7

Everyday walking

1. In the past week, how many days did you walk continually for at least 10 minutes? (For example, walking to the shops, school or your place of work.) *
   0 1 2 3 4 5 6 7
2. On average, how much time did you spend per day walking from place to place?
   1. Hours  
   2. Minutes  

Leisure-time walking

1. Not counting any walking you have mentioned already, over the past week, how many days did you walk continually for at least 10 minutes in your leisure time? *
   0 1 2 3 4 5 6 7
2. On average, how much time did you spend on one of those days walking in your leisure time? *
   1. Hours  
   2. Minutes  

This information will be held by the Ramblers in accordance with the Data Protection Act 1998 and will be kept strictly confidential. All information provided in this and any other questionnaires will go into statistics and it will not be possible to identify your individual responses from any reports we publish. These statistics will be used to judge the effectiveness of the walking programmes. We may use your details to contact you at a later date to find out how helpful you found the programme and to send you our newsletter with hints and tips on walking.

1. Please confirm you have read and understood the above statement.
   This field is required

1. 
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2. If other, please tell us where