Mountain Experience Questionnaire

 
Name:
Email:
Program:
Program Date:
1. What are your objectives for this trip?
2. What is your fitness level? Excellent, good, fair or poor? Excellent   Good   Fair   Poor
3. Describe your fitness program:
4. Please list any medical conditions that would affect your endurance, strength or agility
  If you are participating in a backpacking, walking or multi-sport adventure please skip to question 13 , otherwise please complete questions 5-12 .
5. Please list (with dates) instructional courses you have taken:
6. Please list the climbs/trips (with dates) you have done with guides:
7. Please list the climbs/trips (with dates) you have done with friends:
8. Do you rock climb? If so state the level which you second comfortably. If you lead, at what level do you consistently lead?
9. Please list your experience using ice axe, crampons, on glaciers and on step snow and ice:
10. Briefly outline your ski ability and backcountry experience. What equipment do you ski on?
11. Which of the following skills can you perform?
Crevasse Rescue Self-Arrest
Flat Foot Crampon Front Point Crampon
Place Ice Screws Rappelling
Sticht Plate Belay Munter Hitch Belay
Body Belay Avalanche Transceiver Search
12. Which of the following knots can you tie?
Figure 8 Clove Hitch Tape Knot
Fishermans Double Fishermans Prussik
13. Please list other  backpacking or hiking trips you have done
14. What weight are you comfortable carrying in a backpack