PERSONAL INFORMATION

HEALTH & MEDICAL INFORMATION

LIFESTYLE & FITNESS HISTORY

CONSENT & ACKNOWLEDGEMENT

• I understand that my responses to this questionnaire are confidential and will be used only to tailor my fitness program. FLXX Fitness & Wellness will not use or share my information unless I have provided written authorization, or as required by law or regulation. FLXX Fitness & Wellness will not permit unauthorized access to my health information. Access to my health information by FLXX Fitness & Wellness will be limited to the minimum necessary required for business purposes. My health information will be safely stored, safeguarded, and disposed of in accordance with FLXX Fitness & Wellness’s internal policies. FLXX Fitness & Wellness is not responsible for unauthorized access of my health information if I voluntarily make my health information available for viewing by third parties online (for example on social media). If I answered ‘Yes’ to any of the above questions regarding health concerns, I agree to consult with my physician before beginning any fitness program with FLXX Fitness & Wellness.
• I understand that FLXX Fitness and Wellness trainers are not licensed health care professionals and that I am not establishing a patient-provider relationship with them. I also understand that the fitness services provided by FLXX Fitness and Wellness trainers do not constitute medical, dietary, or therapeutic care, advice, opinion, diagnosis, or treatment. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists. I understand that I should maintain a relationship with a licensed provider who is available to provide emergent and urgent care to me.
• I recognize that FLXX Fitness and Wellness cannot guarantee results or any specific outcomes from the trainer services. I am solely responsible for any action taken based on my interpretation of the information presented by the trainer or engagement with the trainer.