Online Admission Form - Reliant Physical Therapy

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Date	08/21/2025
Patient Information
Formal Name (as on Insurance Card or Driver License)	Natalie Louise McKee
Nickname/Name you liked to be called?	Natalie
Gender	Female
Date of Birth	07/05/1975
Email	Email hidden; Javascript is required.
Address	262 Woodgate Lane Brandon, Mississippi Ms Map It
Home Phone	(601) 586-1495
Cell Phone	(601) 586-1495
Would you like an email or text message reminder about your appointments?	Yes
What type of reminder(s) would you like?	Text Message (2-3 hrs prior to appointment)
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Molina
Primary Insurance ID Number	0003118772
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Natalie Louise Mckee
Primary Insurance: Insured Party DOB	07/05/1975
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	262 Woodgate Lane Brandon, Mississippi Ms Map It
Do you have a secondary Insurance.	No
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Faye Chittom
Emergency Contact 1: Phone Number	(601) 624-6221
Emergency Contact 2: Name	Amber Blakely
Emergency Contact 2: Phone Number	(601) 278-2223
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Neck and back
What side of the body will we be treating?	Both
Date of Injury or when your pain began.	07/01/2023
Is this injury due to:	I’ve had problems with my neck since my cervical fusion in 2015. I’ve managed as best I can. I had a work injury in 2023 and motor vehicle accident on 8/19/24. Since then I’ve noticed a drastic change in my physical condition.
Patient Maritial Status	Single
Briefly describe your symptoms:	I have constant stiffness with tingling and at times stabbing pain in the base of my skulll that radiates into my shoulders upper and lower back and legs. At the moment it seems to be worse on my right side. Please help
How did your symptoms start?	They started after my work injury and were exacerbated after the motor vehicle an accident.
What is your biggest complaint?	Not knowing what I’m doing wrong to cause a flare up of pain. I believe PT will help alleviate and/or manage chronic pain for me. I’m very hopeful
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	Yes
Date of Surgery	09/15/2015
Surgical Procedure:	Cervical spinal fusion C-5,6,&7
Rate your overall health:	Good
Home Layout	One Story Home Combo Tub/Shower
Living Situation	Lives with Family
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	34 years
On average, about how many packs per day did or do you smoke?	.5/day
Do you have a history of falling?	No
Have you had prior physical therapy, occupational therapy or chiropractic treatment this year?	Yes
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Quite a Bit
Please check or describe any limitations you have experienced in your Self Care:	Hygiene Sleeping Bathing Dressing Toileting Eating Chores Driving Caregiving
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home Food Prep Housekeeping Laundry Transportation Negotiating Obstacles Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Kneeling Squatting Transferring from Bed to Chair Housekeeping Laundry Transportation
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Fine Hand Use Work/Vocation/Occupation Recreation Kicking/Pushing with Legs Pulling/Pushing Objects
Pain
Where is the location of your pain?	My neck upper and lower back arms and legs
What is the WORST your pain gets on a 0 - 10 Scale?	8/10
What is the BEST your pain gets on a 0 - 10 Scale?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	6/10
Pain Description (Please check all that apply)	Burning Sharp Dull/Achy Throbbing Shooting Numbness/Tingling Constant Intermittent
What makes your pain worse?	Sitting Standing Walking Going Up Stairs Going Down Stairs Standing Bending Using the Bathroom Lying Down
What makes your pain better?	I have to have an inner conversation with myself everyday. At the moment I’m in a lot of pain. It could have been aggravated because I dusted and vacuumed a few rooms in my house. Did some laundry and unloading the dishwasher. I do PT at home and try to stretch each day. The weather could be a factor. At this point I don’t really know if it’s one specific thing. It’s aggravating though.
Employment
Are you employed?	Yes
Patient Employer	Self-employed
Occupation	Delivery Driver
Patient Employment Status	Part Time
Duty Level of Work:	Light
Are you currently working?	Yes, but on Modified or Light Duty
What are your job restrictions?	Light duty
Patient Employer Address	262 Woodgate Lane Brandon, Mississippi 39042 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Lancon
Medical History
Have you had any diagnostic imaging studies for this injury?	MRI, CT scan, reflexive X-ray
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications Vitamin/Mineral/Dietary Supplements
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Movie, Zanaflex,, Medical Marijuana
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Tylenol arthritis
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	D-3, and calcium
Please list any allergies you may have and your bodies response to this allergy.	Cipro that caused severe pain in my neck and upper back
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Left knee surgery for a torn meniscus and cervical fusion in C-5,6,&7
What are your goals from physical therapy?	To get strengthened in my weak areas so my muscles can support these weak bones. Learning the proper way to stretch and strengthen so I can continue my own at home PT.
Please list a primary functional activity that you have difficulty performing.	There are many activities that I have a problem functioning and doing when the pain hits me and it’s just typical every day chores around the house that I have difficulty doing when this pain comes.I
How much difficulty do you have in performing this first task?	7/10
Please list a second functional activity that you have difficulty performing.	I also find it difficult to drive because I have to turn my body and use my arms and my legs to drive and all of the muscles that are necessary to drive are the muscles that are bothering me and joints that are bothering me
How much difficulty do you have in performing this second task?	7/10
Please list a third functional activity that you have difficulty performing.	At the worst time, I find it difficult to sleep even and find a comfortable position
How much difficulty do you have in performing this third task?	7/10
Are you currently receiving home health services?	No Yes
Consent for Treatment
Consent 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.
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Referral Source
How did you find out about us?	Online Search
Certification Statement
Patient/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;	Natalie Mckee
Signature