Online Admission Form "*" indicates required fields Date MM slash DD slash YYYY Patient InformationFormal Name (as on Insurance Card or Driver License)* First Middle Last Nickname/Name you liked to be called?Gender* Male Female Date of Birth* MM slash DD slash YYYY Email Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneWork Phone Extension (if applicable)Would you like an email or text message reminder about your appointments? Yes No What type of reminder(s) would you like? eMail Text Message (2-3 hrs prior to appointment) Text Messages:Which clinic will you receive treatment at?* Pearl Kosciusko Flowood Guarantor InformationPatient Relationship to Guarantor. Self Child Spouse Guardian Other Guarantor Name First Middle Last Guarantor Gender Male Female Guarantor Date of Birth MM slash DD slash YYYY Guarantor PhoneGuarantor Address Same as patient Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance InformationPrimary Insurance* Ambetter Aetna Blue Cross Blue Shield Cigna Humana Medicare Magnolia Health - MS CAN/MS CHIP Mississippi Medicaid Molina TriWest TriCare UMR United HealthCare Wellcare Workers Compensation No Insurance - Self Pay Other Primary Insurance ID NumberPrimary Insurance: Patient's Relationship to Insured Party Self Child Spouse Guardian Guarantor Other Primary Insurance: Insured Party Name First Middle Last Primary Insurance: Insured Party DOB MM slash DD slash YYYY Primary Insurance: Insured Party Gender Male Female Primary Insurance: Insured PhonePrimary Insurance: Insured Address Same as patient Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a secondary Insurance. Yes No Secondary InsuranceSecondary Insurance ID NumberSecondary Insurance: Patient's Relationship to Insured Party Self Child Spouse Guardian Guarantor Other Secondary Insurance: Insured Party Name First Middle Last Secondary Insurance: Insured PhoneSecondary Insurance: Insured Party DOB MM slash DD slash YYYY Secondary Insurance: Insured Party Gender Male Female Secondary Insurance: Insured Address Same as patient Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this a worker's compensation or other accident claim? Yes No Claim NumberCase Worker/Adjustor's Name: First Last Case Worker/Adjustor's Phone NumberCase Worker/Adjustor's Phone Extension (if applicable)Did a doctor refer you to physical therapy? Yes No What doctor referred you to therapy? Doctor's Name Emergency ContactsEmergency Contact 1: Name First Last Emergency Contact 1: Phone NumberEmergency Contact 2: Name First Last Emergency Contact 2: Phone NumberBasic InformationWhat part of your body will we be treating today? (hip, knee, back...)What side of the body will we be treating? Left Right Both Neck Back NA Other Date of Injury or when your pain began. MM slash DD slash YYYY Is this injury due to: Fall Work Related Sports Related Motor Vehicle Accident Other What state did the MVA occur in?Patient Maritial Status Married Single Divorced Other Briefly describe your symptoms:How did your symptoms start?What is your biggest complaint?How often do you experience your symptoms? Constantly (76-100% of the time) Frequently (51-75% of the time) Occasionally (26-50% of the time) Intermittently (0-25% of the time) Did you have surgery? Yes No Date of Surgery MM slash DD slash YYYY Surgical Procedure:Rate your overall health: Excellent Very Good Good Fair Poor Home LayoutOne Story HomeTwo Story HomeCondo/AptStairs/StepsShower StallCombo Tub/Shower(Hold Ctrl to select multiple items)Living Situation Lives with Family Lives Alone Lives with Caregiver Do you now or have you ever smoked? No Yes How many years did or have you smoked?On average, about how many packs per day did or do you smoke?Do you have a history of falling? No Yes How many falls have you had in the past year?Have you had prior physical therapy, occupational therapy or chiropractic treatment this year? No Yes Current Functional LimitationsHow much have your symptoms interfered with your usual daily activities Not at All A Little Bit Moderately Quite a Bit Extremely Please check or describe any limitations you have experienced in your Self Care:HygieneSleepingBathingDressingToiletingEatingChoresDrivingCaregiving(Hold Ctrl to select multiple entries)Please check or describe any limitations you have experienced in your Mobility:Walking at HomeUse of Walking Aid(walker, crutches, cane...)Food PrepHousekeepingLaundryTransportationNegotiating ObstaclesShopping(Hold Ctrl to select multiple entries)Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:Prolonged SittingProlonged StandingKneelingSquattingTransferring from Bed to ChairHousekeepingLaundryTransportation(Hold Ctrl to select multiple entries)Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:Hand and Arm UseFine Hand UseWork/Vocation/OccupationRecreationKicking/Pushing with LegsPulling/Pushing Objects(Hold Ctrl to select multiple entries)PainWhere is the location of your pain?What is the WORST your pain gets on a 0 - 10 Scale? 0/10 - No Pain 1/10 2/10 3/10 4/10 5/10 - Moderate Pain 6/10 7/10 8/10 9/10 10/10 - Severe Pain What is the BEST your pain gets on a 0 - 10 Scale? 0/10 - No Pain 1/10 2/10 3/10 4/10 5/10 - Moderate Pain 6/10 7/10 8/10 9/10 10/10 - Severe Pain What is your pain RIGHT NOW on a 0 - 10 Scale? 0/10 - No Pain 1/10 2/10 3/10 4/10 5/10 - Moderate Pain 6/10 7/10 8/10 9/10 10/10 - Severe Pain Pain Description (Please check all that apply)BurningSharpDull/AchyThrobbingShootingNumbness/TinglingConstantIntermittentWorse in AMWorse in PMWorse at night while sleeping(Hold Ctrl to select multiple entries)What makes your pain worse?SittingStandingWalkingGoing Up StairsGoing Down StairsStandingBendingUsing the BathroomLying DownCoughing/Sneezing(Hold Ctrl to select multiple entries)What makes your pain better?EmploymentAre you employed? Yes No Patient EmployerOccupationPatient Employment Status Full Time Part Time Disabled Out of Work Other Duty Level of Work: Very Light Light Medium Heavy Very Heavy Other Are you currently working? Yes - Regular Duty Yes, but on Modified or Light Duty No Other Off work since:What are your job restrictions?Patient Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you disabled or currently on disability? Yes No When did you become disabled or on disability?What is the reason you are disabled?(this may impact your prognosis, available treatment options...) Medical HistoryDo you have any of the following medical conditions? (Check all that apply)I have no significant Medical HistoryAlzheimer'sHistory of CancerCardiovascular IssuesHuntington'sCauda EquinaImmunosuppressionStrokeLupusCurrent InfectionMuscular DystrophyDiabetes Type 1Diabetes Type 2ObesityOsteoarthritisParkinson'sFibromyalgiaFractureRheumatoid ArthritisHigh Blood PressureTraumatic Brain InjuryHIV/AIDSBleeding DisorderSeizuresFainting SpellsPacemakerCurrently PregnantOther(Hold Ctrl to select multiple entries)Have you had any diagnostic imaging studies for this injury? X-Ray MRI CT Scan Other Have you had any recent or unexplained weight loss? Yes No Are you taking any of the following?Prescription MedicationsOver the Counter MedicationsHerbal SupplementsVitamin/Mineral/Dietary SupplementsOther(Hold Ctrl to select multiple entries)Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.Please list the Other medications you are taking. You may bring in a list if you prefer to do so.Please list any allergies you may have and your bodies response to this allergy.Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)What are your goals from physical therapy?Please list a primary functional activity that you have difficulty performing.This may be one of the activities you checked earlier that were limited. How much difficulty do you have in performing this first task? 0/10 - Unable to Perform 1/10 2/10 3/10 4/10 5/10 - Moderate Difficulty 6/10 7/10 8/10 9/10 10/10 - No Problem or Difficulty Performing Please list a second functional activity that you have difficulty performing.This may be one of the activities you checked earlier that were limited. How much difficulty do you have in performing this second task? 0/10 - Unable to Perform 1/10 2/10 3/10 4/10 5/10 - Moderate Difficulty 6/10 7/10 8/10 9/10 10/10 - No Problem or Difficulty Performing Please list a third functional activity that you have difficulty performing.This may be one of the activities you checked earlier that were limited. How much difficulty do you have in performing this third task? 0/10 - Unable to Perform 1/10 2/10 3/10 4/10 5/10 - Moderate Difficulty 6/10 7/10 8/10 9/10 10/10 - No Problem or Difficulty Performing Are you currently receiving home health services? No Yes Consent for TreatmentConsent for Treatment* I, the patient/guardian, acknowledge that I am of a sound mind and physically/mentally able to give consent for my/my dependent's care. I hereby give consent to receive outpatient physical therapy services as deemed necessary by the therapist(s) on duty at Reliant, Inc. I am aware that the practice of physical therapy is not an exact science and I acknowledge that no guarantees have been made regarding my treatments, results or outcomes. I understand that in some cases, treatment techniques may actually increase my pain. I understand that proper evaluation and treatment may require bodily contact, touching and/or direct contact by the therapists. I have reviewed the Patient Consent Form, Dry Needling Consent Form and Privacy Policy at the hyperlinks below. I am aware that as the patient/guardian I have the right to decline and/or refuse any portion of my treatment that I decide not to participate in. Patient Consent FormDry Needle Consent Form Reliant Privacy PolicyELECTRONIC NEWSLETTER:Electronic Newsletter In an ongoing effort to provide our patients with continued education and the latest healthcare information you may choose to receive monthly emails from our company. You may opt-out at any time, if you prefer to receive our monthly newsletter please sign up above on our online admission form. Referral SourceHow did you find out about us? Online Search Phone Book Doctor Other Certification StatementPatient/Guardian Signature* By signing below, I certify that I am the patient or have legal rights to sign on the patient's behalf. Furthermore, I have read and understand the statements and policies that have been stated above. I also certify that I have provided correct information to the best of my knowledge. I hereby authorize payment directly to Reliant, Inc. for medical services rendered. I authorize the release of my medical information deemed necessary in the processing of my medical claims. Form Completed By;* First Last (Must be the Patient, Guardian or other legal caretaker)Signature*Must be Patient, Guardian or other legal caretaker.PhoneThis field is for validation purposes and should be left unchanged.
