1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

   Yes No
   If YES, Explain:
2. Do you feel pain in your chest when you do physical activity?

   Yes No
   If YES, Explain:
3. In the past month, have you had chest pain when you were not doing physical activity?

   Yes No
   If YES, Explain:
4. Do you lose your balance because of dizziness or do you ever lose consciousness?

   Yes No
   If YES, Explain:
5. Do you have a bone or joint problem (for example, neck, shoulder, back, knee or hip) that could be made worse by a change in your physical activity?

   Yes No
   If YES, Explain:
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, cholesterol or heart condition?

   Yes No
   If YES, Explain:
7. Do you know of any other reason why you should not do physical activity?

   Yes No
   If YES, Explain:

Informed Consent / Assumption of Risk:

I, , am aware that there are significant risks involved in all aspects of physical training. I understand that the reaction of the heart, lungs and vascular system to exercise cannot always be predicted with accuracy. I understand that there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart rate; chest, arm or leg discomfort; transient light-headedness or fainting; and in rare instances, heart attack, stroke or even death. Excessive work can result (in rare cases) in exertional rhabdomyolosis. I should look for signs of excessive soreness, darkened urine, and pain in the kidney areas in the days following a particularly intense workout. While this type of injury is relatively rare, it can occur due to a number of factors, including (but not limited to) genetic predisposition or dehydration, that may be beyond the control of my trainer. I understand that the programs and classes offered by HighAltitude CrossFit are of a nature and kind that are extremely strenuous and can/may push me to the limits of my physical abilities. These risks include, but are not limited to: falls which can result in serious injury or death, injury or death due to negligence on the part of myself, my training partner, or other people around me, injury or death due to improper use or failure of equipment. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s).