Nutrition Intake Form

*Note: All fields marked with an asterisk (*) are required.

*Location
 

*First Name:
*Last Name:
*Email
*DOB:
Is patient Responsible Party
*Best Contact Number

Responsible Party
First Name
Last Name
DOB

Referring Physician:
Primary Care Physician (if different)

Preferred Pre-Appointment Contact Method (check any/all desired):
If none selected, text reminders will be sent

How did you hear about Viverant?
If you selected other, please explain here:
 

Lifestyle Questions

What is the reason for your visit today?
Other:
What, if any, specific diet are you following?
Do you have any food preferences?
Other:
Date of last doctor's visit:
Reason for doctor's visit:

Have you seen a registered dietitian in the past?
If yes, what was the outcome of that visit?

On average, how many hours of sleep per night do you get?
Per weeknight:
Per weekend night:

How often to you exercise per week?
Please list any physical/medical limitations preventing/limiting your ability to exercise:
Please list any dietary restrictions, food allergies/intolerances you have:
Please list any prescribed and over-the-counter (OTC) medications you are currently taking:
Please select your stress level (0 = no stress, 10 = greatest possible stress):
 

Do you make yourself sick because you feel uncomfortably full?

Do you worry you have lost control over how much you eat?

Have you recently lost more than 15 pounds in a three-month period?

Do you believe yourself to be fat when others say you are too thin?

Would you say that food dominates your life?

Employer Information

Employer Name:
Occupation:
What type of activities do you regularly perform while at work?
Other:

Medical History

Check if you have experienced or currently experiencing any of the following:

Smoker
Packs a day:
Have you ever quit?

Alcohol
Drinks per week:

Caffeinated drinks
Drinks per week:

Surgery in past 12 months
Details:

Eating disorders
Details:

Hospitalizations in past 12 months
Details:

Allergies
Details:

Headaches
Diabetes
Rheumatoid Arthritis

Osteoporosis
Thyroid condition
High blood pressure

Polycystic ovary syndrome
Asthma
Fever

Swelling
Chemical dependancy
Ear/Eye conditions

Taking an immunosuppressant
Depression
Gastrointestinal disease(s)

Hepatitis
Shortness of breath
Angina

Ulcers
Nausea/Vomiting
History of a stroke

Night sweats
Dizziness
Unexplained weight changes

Bladder changes
Recent diarrhea
Difficulty swallowing

Fibromyalgia
Cardiovascular disease
Heart condition(s)

Lung disease
Kidney disease

Other medical conditions/symptoms:
 

Please check any family medical conditions below

High Blood Pressure

Heart Attack

High Cholesterol

Stroke

Diabetes

Congenital Heart Defect

Heart-related Surgeries

Early Death

Other family medical conditions?
 

Please add any other information you would like your dietitian to know:
Please list your Top 3 goals to accomplish through nutritional counseling:
1.
2.
3.

Please select your level of desire to improve your health and fitness (0 = no desire, 10 = greatest)
 

Viverant Consent Terms & Conditions

I, the patient, do hereby voluntarily consent to such care encompassing diagnostic procedures and medical treatment as ordered by the prescribing physician, his/her assistant(s), consultant(s), as is necessary in his/her professional judgment. I assume responsibility for discussing and understanding my proposed treatment and goals based on the evaluation with my practitioner, as well as expected benefits and potential risks and drawbacks of the evaluation and service, and understand treatment does not guarantee an improvement in patients current condition.

I hereby authorize Viverant, its employees or agents, to release medical information regarding myself and my current condition(s) to my insurance company for purposes of payment and/or quality reviews; and referring, consulting, treating physicians, or other medical providers as necessary to support continuity of care. This authorization will remain valid until mutually revoked in writing by both the patient and Viverant. I understand that Viverant has made a copy of their Notice of Privacy Practices available for my review, and that I can request a copy at anytime in writing or by contacting a Viverant office representative. I give Viverant consent to utilize photos and/or written/verbal testimonials for marketing purposes, and authorize Viverant to utilize my contact information, such as email addresses or phone numbers, to correspond with me information not considered Protected Health Information (PHI).


I have read Viverant's Consent to Treat and agree to all terms and conditions *Terms and Conditions
 

Viverant Patient Billing Agreement

I, the patient, understand that I am responsible for communication with my insurance company regarding any co-payments, deductibles, or provider information pertaining to my treatment at Viverant. I understand that I am responsible for obtaining any required referrals from primary care clinics. I understand I am ultimately responsible for any charges not covered by third party payers. I attest that I am not currently receiving or enrolled in home health services. I agree to notify Viverant in writing if I begin home health services, and acknowledge that failure to notify Viverant in writing will result in my being financially responsible for services rendered, up to $160 per visit. I have reviewed the various fee/payment scenarios and understand that I am responsible for all outstanding balances. I also understand that, any balance on my account over 60 days outstanding, after insurance has processed said claim(s), is subject to 3% interest fee per month; any account 90 days outstanding, or in collections for non-payment, will assess a $50 processing fee and will require payment in full prior to further treatment. Any patient payments returned for insufficient funds will be assessed a $20 NSF fee. In addition, I understand that I am responsible for any equipment or supplies purchased specifically for my treatment, and I will be billed for any such supplies over $10.00 in value. I also understand if I schedule and fail to show for an appointment, or fail to give 1 business day notice of my cancellation, Viverant may charge me a No-Show fee of $50? and any translation/interpreter charges incurred due to lack of notice ?, and after 2 occurrences may result in appointment scheduling restriction to same-day scheduling only.

I understand that if I choose Viverant's Self-Pay payment option, I agree NOT to solicit reimbursement from any third party payer for Self-Pay services received at Viverant. I understand each individual Self-Pay treatment purchased must be redeemed within 12 months of purchase before expiration. I also understand if I choose not to utilize self-pay, Viverant is not able to withdraw claims already submitted to my insurance. If I select Viverant's self-pay services, I understand Viverant is NOT able to withdraw claims already submitted to insurance to switch to self-pay, and is NOT able to reprocess self-pay claims to insurance. 

I agree I am responsible for notifying Viverant within 30 days of change in insurance coverage, or termination of existing coverage. If I fail to do so within that timeframe, I will be responsible for full balance due of services rendered. If I notify Viverant of new insurance after services have already been rendered, and insurance will not cover services due to plan-level requirements not being met (such as but not limited to MD Orders, Prior Authorization), I agree to be responsible for full balance due of services rendered.

I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make a claim against, sue, or attach the property of Viverant or any agent of Viverant on account of injury or damage resulting from the negligence or other acts, howsoever caused, by any employee, agent, or contractor of Viverant. I hereby release Viverant from all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my treatment at Viverant.

If applicable, I authorize third party payment directly to Viverant of the benefits otherwise payable to me. Those charges are not to exceed the regular charges for this period of treatment. If I have sought litigation due to my injury and refuse to provide the appropriate insurance information, I understand that I am required to pay Viverant at the time services are provided. I also understand that if I have filed a Workers Compensation claim and my claim is denied, I will then be responsible for payment of services as they are received if I do not provide health insurance. I understand I am financially responsible to Viverant for charges not covered by this authorization.


I have read Viverant's Privacy Practices Statement (or waive my right to read this document) and understand my privacy rights as they pertain to treatment at Viverant *Patient Billing Agreement

 

Physical Activity Readiness Questionnaire (PAR-Q)

If you are planning to become much more physically active than you are presently, please answer the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, check with your doctor.
Please read the 5 questions below carefully. If you can answer NO to each of them, please check the box below:
  1. Has your doctor ever said that you have a heart condition and you should only do physical activity recommended by a doctor?
  2. Do you feel pain in your chest when you do physical activity?
  3. In the past month, have you had chest pain when you were not doing physical activity?
  4. Do you lose your balance because of dizziness or do you ever lose consciousness?
  5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
  6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
  7. 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 by phone or in person BEFORE you start becoming much more physically active and BEFORE you have a fitness appraisal. If you proceed with physical activity, you do so knowing any possible inherent risk.

I have read, understood, and answered NO to the 7 Par-Q questions above.
 
I authorize Viverant to release information including the diagnosis, records, examination and claims information to person(s) other than myself.
 

 
Release for "other" information