Online Admission Form - Reliant Physical Therapy

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Date	08/25/2025
Patient Information
Formal Name (as on Insurance Card or Driver License)	Carolyn Scott Ann
Gender	Female
Date of Birth	08/01/1962
Address	528 fox run trail Apt C5, Mississippi Pearl Map It
Cell Phone	(769) 209-5700
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?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Medicare
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party DOB	08/01/1962
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	528 fox run trail Apt C5, Mississippi Pearl 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	Britney Henry
Emergency Contact 1: Phone Number	(769) 209-5700
Emergency Contact 2: Name	Gennifer Donald
Emergency Contact 2: Phone Number	(601) 760-0125
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Legs
What side of the body will we be treating?	Both
Patient Maritial Status	Other
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	Yes
Rate your overall health:	Poor
Living Situation	Lives with Family
Do you now or have you ever smoked?	No
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
Pain
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?	5/10 - Moderate Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	7/10
What makes your pain worse?	Standing
What makes your pain better?	Sitting
Employment
Are you employed?	No
Are you disabled or currently on disability?	Yes
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	Yes
Are you taking any of the following?	Prescription Medications Over the Counter Medications Vitamin/Mineral/Dietary Supplements
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Had surgery on a blocked artery in my right leg
What are your goals from physical therapy?	To walk again
Please list a primary functional activity that you have difficulty performing.	Standing to cook
How much difficulty do you have in performing this first task?	0/10 - Unable to Perform
Please list a second functional activity that you have difficulty performing.	Getting in car
How much difficulty do you have in performing this second task?	1/10
Please list a third functional activity that you have difficulty performing.	Going up stairs
How much difficulty do you have in performing this third task?	0/10 - Unable to Perform
Are you currently receiving home health services?	No
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.
ELECTRONIC MONTHLY NEWSLETTER:
Electronic Monthly 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 Source
How did you find out about us?	Doctor
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;	Britney Henry
Signature