physical Activity readiness questionnaire & waiver Name * First Name Last Name Age, Weight, and Height * Date of Birth * MM DD YYYY Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you perform physical activity? * Yes No In the past month, have you had chest pain when you were not performing any physical activity? * Yes No Do you lose your balance because of dizziness, or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Yes No Is your doctor currently prescribing any medication for your blood pressure or a heart condition? * Yes No Do you know of any other reason why you should not engage in physical activity? * Yes No I, ______________ have enrolled in a program of strenuous physical activity including, but not limited to resistance training, strength and conditioning, and aerobic endurance offered by CoachingBySam, I hereby affirm that I am in good physical condition and do not suffer from any disability which will prevent or limit my participation in this exercise program. In consideration of my participation in services provided by CoachingBySam, I, for myself, my heirs and assigns, hereby release Samantha Ulysse, from claims, demands and causes of action arising from my participation in all services. I voluntarily assume all risks of injury, including death, however caused during or after my participation in services provided by CoachingBySam. I hereby affirm that I have read and fully understand the above. * Today's Date * MM DD YYYY Thank you!