Patient Application

At TENNACITY we are seeking trauma survivors whose lives have been significantly affected by serious trauma and who are motivated to overcome challenges, expectations, and diagnoses to return to living a fulfilling lifestyle. Our ideal patient is one is motivated and who is willing to fight to regain their independence and health.

Our team at TENNACITY takes the application process very seriously and seeks as much information as possible in order to make determinations on whether applicants are qualified for our program. Please provide as much detailed information as possible on this application as it will help our team make the best determination possible.

Please note that TENNACITY provides payment to your care provider directly. No funds will ever be given directly to you during the TENNACITY program.

If you have any questions while filling out this form, please email thomas@tennacityfoundation.org or call 615-332-2513.

Counties TENNACITY Currently Serves:

Williamson
Davidson
Maury
Bedford
Rutherford
Sumner
Montgomery

The Application Process:

Step One: Complete this application and fill out all applicable fields with as much information as possible.

Step Two: TENNACITY’s Advisory Board of healthcare professionals will review your application and determine whether you meet our basic criteria. Applications are reviewed monthly, starting on the 15^th of the month.

Step Three: TENNACITY’s Advisory Board will make a recommendation on what type of treatment is most appropriate for you, and what facility best meets your needs

Step Four: If you are selected as a top candidate by our Advisory Board, a one-on-one phone or in-person interview will be conducted with you and one of our team members

Step Five: You will receive notification of acceptance or rejection from TENNACITY, the treatment recommended, and the sponsorship level TENNACITY can provide via email. Please provide the best email address to reach you at on your application.

Step Six: Begin your journey to an active and fulfilling life!

Section One: General Information
Name*
First Last
DOB*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Email*
Phone*
Do you have reliable transportation?*
- Yes
- No
Ethnicity*
How did you hear about TENNACITY?*
Section Two: Health/Trauma Information
Prior Health Conditions*
Current Medications (List name, dosage, and frequency of medication)*
Date of Injury/Trauma*
MM slash DD slash YYYY
Date of Hospital Admission*
MM slash DD slash YYYY
Description of Injury/Trauma (Describe & summarize the accident or trauma event)*
Trauma/injuries sustained (List all injuries or trauma as a result of the event):*
Are You Currently In the Hospital?*
Date of hospital discharge*
MM slash DD slash YYYY
Your expected discharge date*
MM slash DD slash YYYY
Section Three: Treatment Information
Did you undergo any surgeries or procedures?*
- Yes
- No
If so, please describe below with date of surgery/procedure*
What type of therapy have you received to this point?*
When was your last therapy session, and with who?*
Current Limitations*
Permanent Limitations*
Section Four: Rehabilitation Goals
What are your short-term goals for rehabilitation? (6-12 months)*
What are your long-term goals for rehabilitation? (1 year+)*
What is currently preventing you from accomplishing these goals?*
Why should TENNACITY accept you and sponsor your treatment?
Section Five: Financial Information
TENNACITY is proud to provide treatment for our participants at discounted rates from our partners.

The average cost of our personal training program is $750. The average cost of our physical therapy program is $800.
Please select your preference below*
*Due to limited funds we are not able to provide full scholarships to all applicants. Should you not receive a full sponsorship, we will revisit payment options at that time.
- I agree to pay the full amount of my discounted treatment.
- I would like to apply for a full or partial scholarship.*
Please be aware that there is a $50 fee required of all approved participants, whether you receive a full, partial, or no sponsorship from TENNACITY.
Current annualized household income*
Number of dependents in the household*
Do you have medical insurance?*
- Yes
- No
What is your deductible?*
What is your out-of-pocket maximum?*
Have you met your deductible?*
- Yes
- No
Have you met your out-of-pocket maximum?*
- Yes
- No
Do you have government provided health insurance?*
- Yes
- No
Amount have you spent on medical treatment to this point related to this specific trauma?*
Amount spent on non-medical costs related to this specific trauma?*
i.e. travel costs, time off work, transportation, etc.
Do you have short-term or long-term disability insurance?*
- Yes
- No
Has your income been affected as a result of this event?*
- Yes
- No
If yes, explain*
Has your income been affected for the long-term as a result of this event?*
- Yes
- No
If yes, explain*
The Physical Activity Readiness Questionnaire (2018 PAR-Q+)
Please fill out this section as it applies to your previous medical history. Please read the questions below carefully and answer each one honestly.
General Health Questions
Has your doctor ever said that you have a heart condition OR high blood pressure?*
- Yes
- No
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
- Yes
- No
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?*
*Please answer NO if your dizziness was associated with over-breathing or vigorous exercise
- Yes
- No
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*
- Yes
- No
Please list conditions*
Are you currently taking prescribed medications for a chronic medical condition?*
- Yes
- No
Please list conditions and medications*
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?*
*Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.
- Yes
- No
Please list conditions*
Has your doctor ever said that you should only do medically supervised physical activity?*
- Yes
- No
Follow-Up Questions About Your Medical Conditions
1) Do you have arthritis, osteoporosis, or back problems?*
- Yes
- No
1a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?*
*Answer NO if you are not currently taking medications or other treatments.
- Yes
- No
1b) Do you have joint problems, causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebrae, and/or spondylolysis/par defect?*
- Yes
- No
1c) Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
- Yes
- No
2) Do you currently have Cancer of any kind?*
- Yes
- No
2a) Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
- Yes
- No
2b) Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?*
- Yes
- No
3) Do you have a Heart or Cardiovascular Condition?*
*This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Hearth Rhythm?
- Yes
- No
3a) Do you have difficulty controlling your condition with medications or other physician prescribed therapies?*
*Answer NO if you are not currently taking medications or other treatments
- Yes
- No
3b) Do you have an irregular heart beat that requires medical management?*
- Yes
- No
3c) Do you have chronic heart failure?*
- Yes
- No
3d) Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
- Yes
- No
4) Do you have High Blood Pressure?*
- Yes
- No
4a) Do you have difficulty controlling your condition with medications or other physician prescribed therapies?*
- Yes
- No
4b) Do you have a resting blood pressure equal to or greater than 160/90 mmHG with or without medication?*
*Answer YES if you do not know your resting blood pressure
- Yes
- No
5) Do you have any Metabolic Conditions?*
*This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes.
- Yes
- No
5a) Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?*
- Yes
- No
5b) Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living?*
*Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.
- Yes
- No
5c) Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
- Yes
- No
5d) Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
- Yes
- No
5e) Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
- Yes
- No
6) Do you have Mental Health Problems or Learning Difficulties?*
*This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome.
- Yes
- No
6a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?*
*Answer NO if you are not currently taking medications or other treatments
- Yes
- No
6b) Do you have Down Syndrome AND back problems affecting nerves or muscles?*
- Yes
- No
7) Do you have a Respiratory Disease?*
*This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure.
- Yes
- No
7a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?*
*Answer NO if you are not currently taking medications or other treatments
- Yes
- No
7b) Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
- Yes
- No
7c) If asthmatic, do you currently have symptoms of chest tightness, wheezing, labored breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
- Yes
- No
7d) Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
- Yes
- No
8) Do you have a Spinal Cord Injury?*
*This includes Tetraplegia and Paraplegia.
- Yes
- No
8a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?*
*Answer NO if you are not currently taking medications or other treatments
- Yes
- No
8b) Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?*
- Yes
- No
8c) Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
- Yes
- No
9) Have you had a Stroke?*
*This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event.
- Yes
- No
9a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?*
*Answer NO if you are not currently taking medications or other treatments
- Yes
- No
9b) Do you have any impairment in walking or mobility?*
- Yes
- No
9c) Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
- Yes
- No
10) Do you have any other medical condition not listed above or do you have two or more medical conditions?*
- Yes
- No
10a) Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
- Yes
- No
10b) Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
- Yes
- No
10c) Do you currently live with two or more medical conditions?*
- Yes
- No
Please list your medical condition(s) and any related medications here*
Participant Declaration
- All persons who have completed the PAR-Q+ please read and sign the declaration below.
- If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.
Participant Declaration*
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that TENNACITY and TENNACITY partners may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. I hereby certify that the information provided throughout this form is fully accurate to the best of my knowledge.
Email Communication Authorization
Authorization To Use Or Disclose Confidential Information Via Electronic Means*
You have the right to request that confidential or otherwise protected information, including Protected Health Information about you that is maintained electronically by TENNACITY be sent to you via unencrypted email. Before transmitting this information, TENNACITY must first advise you of the risks associated with transmitting unencrypted email. Please review the “WARNING REGARDING USE OF E-MAIL” below in which we notify you of these risks. If after reviewing the Warning you decide that you want to receive communications via unencrypted email, then complete the form below and we will transmit information by e-mail. TENNACITY is not responsible for unauthorized access of protected information, including Protected Health Information, while in transmission to you based on your request and is not responsible for safeguarding information once delivered to you.

NOTE: TENNACITY does not maintain original medical records.

WARNING REGARDING USE OF E-MAIL
TENNACITY uses unencrypted e-mail to communicate with its clients. There are risks to using unencrypted email for personal or confidential information, including protected health information. Those risks include:
* E-mail can be forwarded, intercepted, printed or stored by others without your knowledge or consent.
* Employers generally have the right to access any e-mail received or sent by an employee when using an employer-provided device (e.g., smartphone, tablet, laptop) or e-mail address. This means that your employer may view or store your e-mails and any attachments if you use a work e-mail address or work device.
* E-mails can be misdirected (sent to xyzcom.com instead of xyzcom.net) and accessed or used by third parties.
* E-mail, whether accidentally or intentionally, can be broadcast worldwide immediately and received by many unintended recipients.
* Email is easier to falsify than handwritten or signed documents.
* Backup copies of e-mail may exist even after You have deleted Your own copy.
* Employers and service providers may have a right to archive and inspect e-mails transmitted through their systems.
* Passwords providing access to email can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosure of personal information.
* Encrypted e-mail may not be stored in an encrypted manner on a device or server.
* Criminals send out malicious software (bots, worms, trojan horses and viruses) that may access your e-mail information.
TENNACITY has examined these risks and determined that the rewards far outweigh the risks. TENNACITY is not responsible for any access, use or misuse of an e-mail by a third party. By sending TENNACITY an e-mail or by providing TENNACITY with your e-mail address for electronic communications, you consent to the use of unencrypted e-mail and assume all risks associated with e-mail communications.
I consent to the use of unencrypted e-mail and assume all risks associated with e-mail communications.
Name
This field is for validation purposes and should be left unchanged.

Patient Application

Section One: General Information

Section Two: Health/Trauma Information

Section Three: Treatment Information

Section Four: Rehabilitation Goals

Section Five: Financial Information

The Physical Activity Readiness Questionnaire (2018 PAR-Q+)

General Health Questions

Follow-Up Questions About Your Medical Conditions

Participant Declaration

Email Communication Authorization