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Anytime Fitness Clubs (S. Fargo - 45th St)
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First Name
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Last Name
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Email
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DOB
Is Patient Responsible Party
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Best Contact Number
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DOB
I authorize Viverant to release medical information, including billing details to this emergency contact.
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Emergency Contact Number
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How did you hear about Viverant?
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Search Engine (Google/IE/FF/etc.)
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First Visit Location
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Chanhassen
Duluth
Eagan
Edina
The Fortis Academy
Lakeville
Minnetonka
Nutrition
St. Louis Park
St. Paul
Vadnais Heights
Woodbury
AF Clubs (Apple Valley)
AF Clubs (Cottage Grove)
AF Clubs (Duluth)
AF Clubs (Farmington Eagan Lakeville)
AF Clubs (Inver Grove Heights)
AF Clubs (Rochester)
AF Clubs (Roscoe Woodstock)
AF Clubs (Roseville)
AF Clubs (Savage)
AF Clubs (Maple Grove)
AF Clubs (Machesney Park)
AF Clubs (S. Fargo - 45th St)
What is your primary goal:
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What is your Current Occupation:
What are your job-related demands:
What brings you to Viverant?
When did your injury occur/begin:
How did your injury occur?
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Auto Accident (At Fault)
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Have you been assigned a QRC to assist with management of your case?
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N/A
Does your job require repetitive activities greater than 5% of your day?
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N/A
Does your job require lifting weights beyond 20#s greater than 5% of your day?
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Yes
No
N/A
Does your job require pushing/pulling objects greater than 30# greater than 5% of your day?
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Yes
No
N/A
Due to your injury, have you been out of work for greater than 2 months?
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No
N/A
*
Please select your current pain level below (0 = no pain, 10 = worst pain imaginable):
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0
1
2
3
4
5
6
7
8
9
10
Which side of your body does this problem exist?
Left
Right
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Are you Allergic to latex?
Yes
No
Are you receiving other treatment for this condition?
Yes
No
If yes, where and by whom:
Medical History - Check all that apply
Heart Condition
Osteoporosis
Weakness
Surgeries
Changes in Sensation
Changes in Balance
Fractures
Depression
Recent unexplained Weight Loss
Cancer
Metal Implants
Pain at Night
Low Bone Density
Fever
Bladder Changes
Fatigue
Swelling
Fibromyalgia
Implants
Night Sweats
Thyroid Condition
Headaches
Angina
High Blood Pressure
Dizziness
Smoker
Diabetes
Rheumatoid Arthritis
Shortness of Breath
If you answered Yes to any of the above questions, please provide the details below.
Current medication list:
Are you currently enrolled in Home Health Care (HHC)?
Yes
No
*
Do you feel safe in your environment?
Yes
No
*
In the last 2 weeks have you felt down, depressed or have a sense of hopelessness?
Yes
No
*
Over the past 2 weeks, have you felt little pleasure or interest in doing things?
Yes
No
Any Other Information You Would Like Your Therapist To Know:
Viverant Consent Terms & Conditions and Billing Agreement
Billing and Consent
Privacy Practices
Understanding Healthcare Costs
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Term, Condition, Patient Billing and Cancellation Policy Agreement
I have read Viverant's Consent to Treat and Billing Agreement and agree to all terms and conditions
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Privacy Practices Agreement
I have read Viverant's Privacy Practices Statement and understand my rights as they pertain to treatment at Viverant
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Please select one of the following to inform Viverant how to set up your account:
I would like to use Insurance
I would like to use Viverant's Self-Pay
Physical Activity Readiness Questionnaire (PAR-Q)
If you are planning to become more physically active than you are presently, please answer the questions below. If you are between the ages of 15 and 69, this PAR-Q will tell you if you should consult a doctor before you start. If you are over 69 years of age, check with your doctor.
Please click here to read the questionnaire. If you can answer NO to each of them, please check the box below:
Has a doctor ever said you have a heart condition and should only do doctor-recommended physical activity?
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 your 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?
If you answered yes to one or more questions:
Talk with your doctor BEFORE you start becoming more physically active and BEFORE you have a fitness assessment. If you proceed with physical activity, you do so at your own accord knowing any possible inherent risk.
I have read, understood, and answered NO to the 7 Par-Q questions above.
Attach ID (Drivers' License, other)
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Anytime Fitness Clubs (Farmington Eagan Lakeville)
Anytime Fitness Clubs (Duluth)
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