Online Admission Form - Reliant Physical Therapy

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Date	08/26/2025
Patient Information
Formal Name (as on Insurance Card or Driver License)	Latounya Alexander
Gender	Female
Date of Birth	09/06/1977
Email	Email hidden; Javascript is required.
Address	2515 old Brandon Road Pearl, Mississippi 39208 Map It
Home Phone	(662) 207-2973
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	Workers Compensation
Primary Insurance: Insured Address	Mississippi Map It
Do you have a secondary Insurance.	No
Is this a worker's compensation or other accident claim?	Yes
Claim Number	4A25087DN820001
Case Worker/Adjustor's Name:	Zachary Brinkmoelle
Case Worker/Adjustor's Phone Number	(469) 612-6470
Emergency Contacts
Emergency Contact 1: Name	Jerome Evege
Emergency Contact 1: Phone Number	(601) 699-3102
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Foot
What side of the body will we be treating?	Both
Date of Injury or when your pain began.	07/31/2025
Is this injury due to:	Work Related
Patient Maritial Status	Married
Briefly describe your symptoms:	Burning. Dull, achy, pins and needles,sharp, numbness, throbbing, swelling in both ankles
How did your symptoms start?	After injury
What is your biggest complaint?	Pain
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	One Story Home Stairs/Steps Combo Tub/Shower
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?	No
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Extremely
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Bathing Dressing Toileting Chores Driving
Please check or describe any limitations you have experienced in your Mobility:	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 Housekeeping Laundry Transportation
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Work/Vocation/Occupation Recreation Kicking/Pushing with Legs Pulling/Pushing Objects
Pain
Where is the location of your pain?	The entire foot
What is the WORST your pain gets on a 0 - 10 Scale?	10/10 - Severe Pain
What is the BEST your pain gets on a 0 - 10 Scale?	8/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	9/10
Pain Description (Please check all that apply)	Burning Sharp Dull/Achy Throbbing Shooting Numbness/Tingling Constant Worse in AM
What makes your pain worse?	Standing Walking Standing Lying Down
What makes your pain better?	Nothing
Employment
Are you employed?	Yes
Patient Employer	Amazon
Occupation	Delivery Associate
Patient Employment Status	Full Time
Duty Level of Work:	Very Heavy
Are you currently working?	No
Off work since:	08/14/2025
Patient Employer Address	i55 north frontage rd Jackson, Mississippi 39206 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Penny Lawin
Medical History
Do you have any of the following medical conditions? (Check all that apply)	I have no significant Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Losartan 100 mg
What are your goals from physical therapy?	Full recovery from injury
Please list a primary functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this first task?	3/10
Please list a second functional activity that you have difficulty performing.	Standing
How much difficulty do you have in performing this second task?	5/10 - Moderate Difficulty
Please list a third functional activity that you have difficulty performing.	Driving
How much difficulty do you have in performing this third task?	5/10 - Moderate Difficulty
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?	Medrisk
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;	Latounya Alexander
Signature