FitnessDx Registration
Personal Information
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Contact information
Email *
Your answer
Telephone number *
Your answer
Mailing Address: Street or PO Box *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Emergency Contact Person
Name of Person *
Your answer
Phone of emergency contact person *
Your answer
Personal Health History
Review the questions below and circle Yes or No for each. You may use empty boxes to include any other chronic medical conditions or events not covered in the list of questions.
Smoke or use tobacco? (now or previously) *
Diabetes? *
High blood pressure (hypertension)? *
High cholesterol (lipids)? *
Blood clots or clotting disorder? *
Vascular disease (atherosclerosis)? *
Asthma or COPD or lung disease? *
Irregular heart rhythm? *
Abnormal EKG? *
Atrial fibrillation? *
Pacemaker or defibrillator? *
Currently Pregnant? *
Coronary artery disease? *
Heart “cath” or (coronary) stents? *
Cardiac “bypass” (CABG) surgery? *
Heart Attack? *
Congestive Heart Failure? (CHF) *
Structural (valve) heart disease? *
Enlarged heart? *
Other heart disease? *
Stroke or “mini-stroke” (TIA)? *
Hip, knee or ankle arthritis? *
Hip or knee replacement? *
Hospitalization in past year? *
Seizure disorder? *
Doctor advised not to exercise? *
Medications & supplements
Please list ALL medications (prescription, over-the-counter, supplements, and vitamins) that you currently take or have taken in past 6 months. Just list the name of medication (not all instructions or details are needed)
List all medications, supplements and vitamins. If none, write "none". *
Your answer
Current physical activities and symptoms
Please answer these questions to the best of your ability, or mark "don't know" if uncertain.
Can you walk briskly walk or jog 1 mile without stopping? *
Can you climb 4 flights of stairs without stopping? *
Can you stand from fully squatted position without assistance? *
Do you have any chest pain, pressure or discomfort when physically active? *
Do you have any unexplained or unexpected shortness of breath? *
Have you ever passed out, fainted or gotten very dizzy with physical activities? *
Do you have swelling (edema) of lower legs? *
Do you have any symptoms of heart racing, palpitations or skipped beats? *
Do you have pain that prevents you from walking briskly or climbing stairs? *
Risks of participation
PLEASE REVIEW:

I have completed this questionnaire and answered questions accurately and completely. I understand my medical and health history is a very important factor in determining the safety and risk of undergoing FitnessDx testing.

I understand the FitnessDx staff or supervision physician may deny participation, or may require further medical clearance from a physician based on information provided here.

I understand that not disclosing known health issues or symptoms, may falsely alter risks of participation and that doing so may result in serious injury or medical events, including death.

I understand that this Exercise Tolerance Testing requires walking or running on a treadmill at increasing levels of difficulty (speed and incline) to maximum effort or exhaustion. Although the test will be supervised, there are inherent risks of injury during testing, including, but not limited to muscle strains, cramping, leg joint (hip, knee, ankle) injuries, back injury, feet pain/injury, falls, fainting, heart attack, heart rhythm problems, stroke, disability and death.

*
Required
*
Required
User Agreement
USER AGREEMENT & AUTHORIZATION

By checking the box or signing this agreement, you are indicating that you have read and understand this User Agreement (this "Agreement") and are agreeing to the following terms as an agreement between you (User) and NeuCare LLC. ("NeuCare"), operator of the FitnessDx testing service. You are referred to in the following agreement as "I" or "me."

1. Access to Testing Results. I understand that NeuCare will provide me a copy of my FitnessDx test results within 30 days once fully completed. I will include my name, mailing address, telephone number, email address, and other information as required by the order form. I understand that any incorrect mailing information provided may delay the results being received and/or may give access to unauthorized persons. Any request for future copies test results, including in the event the original report was lost or misplaced, may not be available beyond 90 days beyond date of completed date.

2. Risks and Effects of Testing Results. I understand that there are risks presented by participating in FitnessDx including receipt of testing results by me of information about my health (such as metabolic characteristics or medical conditions) that I would prefer not to know, and which may indicate conditions or problems that may be upsetting to me or even incurable, and I assume those risks.

3. Current Good Health. I represent and warrant that I am in generally good health and have had a recent general medical checkup. To my knowledge, I have no medical conditions, including cardiac pacemaker or implanted cardiac defibrillator (“ICD”), which would prevent me from undergoing basic body measurements and drawing of lab through a venous blood sample.

4. Wellness and Preventive Medical Care. I understand that FitnessDx testing is not a substitute for routine wellness or preventive care planning with a Primary Care Physician or qualified medical provider. I understand that FitnessDx testing does not account for all factors that contribute to health, including but not limited to genetics, chronic conditions, personal medical history, family medical history and lifestyle issues (tobacco use, etc.), and these results should not be taken as a comprehensive assessment of health risks.

5. Primary Care Physician & Medical Care. I understand that FitnessDx and NeuCare strongly encourages me to have a personal Primary Care Physician. I understand that these test results are not a substitute for seeking the advice of a Primary Care Physician or other qualified health care professionals. I agree that I will never delay seeking advice from my primary care physician or other health professionals due to information provided through FitnessDx. I will seek emergency help when needed, and continue to consult with my Primary Care Physician as recommended by them regardless of any results provided by FitnessDx.

6. Gathering and Sharing of Lab Results. Laboratory testing (also known as “biomarkers”) will be performed independent of FitnessDx Services through independently contracted "Testing Laboratories". I will submit samples to Testing Laboratories through a process established by FitnessDx and I may be required to execute waivers and authorizations provided to me at the time my samples are collected. The samples I submit to Testing Laboratories may include blood, saliva, hair and other biological samples and are referred to as my "Laboratory Samples." I will not submit my Laboratory Samples directly to FitnessDx. I understand that testing on my Laboratory Samples may be ordered by FitnessDx without any input or approval from me. Upon my execution of the proper HIPAA Authorization, the results from such testing ("Testing Results") will be sent to NeuCare by Testing Laboratories.

7. Costs and Payments. I acknowledge and agree that I will be responsible for all applicable fees for FitnessDx testing. Fees are established and subject to modification by NeuCare from time to time as determined by NeuCare. I understand that NeuCare will bill me for all Services Fees and for all Goods and Services, and I will pay such invoices when they are due. NeuCare may bill me in advance and may provide NeuCare Services and Goods and Services only after I pay my outstanding bills.

8. Use of My Information. NeuCare will maintain my Registration Information, Health Information, Testing Results, records regarding my orders of Goods and Services and all other information collected by NeuCare from me (collectively all of this information is "My Information") in a computer database maintained by NeuCare to the extent NeuCare determines from time to time, and possibly in hard copy as well. I understand and agree that NeuCare will use My Information in accordance with the NeuCare Privacy Policy located here as it may be modified by NeuCare from time to time under the terms of that policy.

9. HIPAA Acknowledgment and Authorization. I understand and agree that my Health Information, including measurements done directly by FitnessDx testing and results provided to NeuCare by Testing Laboratories, is subject to or protected by HIPAA. I will complete a form (found online at http://neucare.net/fitnessdxhipaa) giving NeuCare authorization to access any testing results performed by third parties, including but not limited to Testing Laboratories, before orderling any FitnessDx Services.

10. Termination and non-refundable payments. Unless earlier terminated pursuant to this Agreement, the term of this Agreement ("Term") will commence upon my checking the "Accept" box or signing this form and will continue for the period of time I am a User to FitnessDx Services. Either party may terminate this Agreement at any time on written notice with or without any reason. Upon termination:

NeuCare will not thereafter share Registration Information with any other party.
NeuCare may continue to use My Information as permitted in the FitnessDx Privacy Policy.
My access rights to Fitness Services shall terminate.
All outstanding fees will become due and payable.
All Sections which by their nature survive termination of this Agreement shall survive.

I understand that, upon termination, I will not receive any refund or partial refund for any charges already billed to my account. I understand and agree that termination of this Agreement is my sole right and remedy with respect to any dispute with NeuCare. This includes, but is not limited to, any dispute related to, or arising out of: (1) any term of this Agreement or NeuCare's enforcement or application of this Agreement; (2) any policy or practice of NeuCare or NeuCare's enforcement or application of these policies; (3) my ability to access and/or use NeuCare Services; (4) any NeuCare software or services provided by or through NeuCare; or (5) the amount or type of fees, applicable taxes, billing methods, or any change to the fees, applicable taxes, or billing methods.

11. Notice . If there is an actual or suspected breach of the security of My Information, or any unpermitted disclosure or use of My Information, and NeuCare is required to provide notice of such actual or suspected breach or unpermitted disclosure or use to me under applicable federal or state law I hereby agree that such notice may be provided by NeuCare by email to the email address provided by me during my member registration, or as updated by me thereafter by written notice to NeuCare.

12. No Warranties. ALL SERVICES AND PRODUCTS PROVIDED as part of FitnessDx BY NeuCare ARE PROVIDED "AS-IS" WITHOUT ANY WARRANTY EXPRESS OR IMPLIED, AND NeuCare DISCLAIMS ALL IMPLIED WARRANTIES, INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A SPECIFIC PURPOSE. Without limiting the preceding sentence, I acknowledge and agree that NeuCare is not responsible for the actions or omissions of Testing Laboratories.

13. Ownership. NeuCare owns all right, title and interest to its methodologies, documents and other materials, and all patent, copyright, trademark, and other rights of any nature arising from FitnessDx testing service or relating in any way thereto ("Intellectual Property Rights"). No right to the Intellectual Property Rights of NeuCare is granted to me except to permit me to use NeuCare Services as a User.

14. Severability. Any provision of this Agreement determined to be void, invalid or unenforceable will be deemed modified to the minimum extent necessary to be effective, valid and enforceable, and the other provisions of this Agreement will in full force and effect and enforceable according to their terms.

*
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of NeuCare. Report Abuse - Terms of Service - Additional Terms