Physical Activity Readiness Questionnaire/Wavier of Liability
Common sense is your best guide when you answer these questions. Please read the
questions carefully and answer each one honestly:

Note: Checking YES to any answer will require you to get a physician’s
clearance before starting a training program.

Date
MM
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DD
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Name *
Your answer
Charity
Your answer
Work Phone
Your answer
Home Phone
Your answer
Employer
Your answer
Email Address *
Your answer
Emergency Contact
Your answer
Emergency Contact's Phone
Your answer
Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of ANY OTHER REASON why you should not do physical activity?
By checking YES in the box below you verify the following: I have read, understood, and completed the questionnaire. I understand there inherent risks, both environmental and training induced, that may occur while engaging in marathon training. By agreeing to sign this form, I release John Furey from any responsibility. *
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Your answer
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