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)	Hannah Speights Sheridan
Gender	Female
Date of Birth	04/30/1996
Email	Email hidden; Javascript is required.
Address	176 Tradition Parkway Flowood, Mississippi 39232 Map It
Cell Phone	(769) 232-7422
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	Blue Cross Blue Shield
Primary Insurance ID Number	869254861M
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Hannah Sheridan
Primary Insurance: Insured Party DOB	04/30/1996
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	176 Tradition Parkway Flowood, Mississippi 39232 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	Evan Sheridan
Emergency Contact 1: Phone Number	(601) 395-3450
Emergency Contact 2: Name	Lisa Speights
Emergency Contact 2: Phone Number	(601) 506-5892
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back
What side of the body will we be treating?	Both
Date of Injury or when your pain began.	07/02/2025
Is this injury due to:	Childbirth/pregnancy
Patient Maritial Status	Married
Briefly describe your symptoms:	Aching, sore
How did your symptoms start?	Gradually
What is your biggest complaint?	Constant pain
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Very Good
Home Layout	One Story Home
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
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Chores Driving Caregiving
Please check or describe any limitations you have experienced in your Mobility:	Food Prep Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Pulling/Pushing Objects
Pain
Where is the location of your pain?	Lower back
What is the WORST your pain gets on a 0 - 10 Scale?	7/10
What is the BEST your pain gets on a 0 - 10 Scale?	3/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Dull/Achy Constant
What makes your pain worse?	Standing Walking Standing Bending
What makes your pain better?	Positioning
Employment
Are you employed?	Yes
Patient Employer	MSPHI
Occupation	Program Manager
Patient Employment Status	Full Time
Duty Level of Work:	Light
Are you currently working?	No
Off work since:	7/2/2025
Patient Employer Address	5 Olympic Way Madison, Mississippi 39110 Map It
Are you disabled or currently on disability?	Yes
When did you become disabled or on disability?	7/2/2025
What is the reason you are disabled?	Childbirth
Medical History
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.	Omeprazole, buspar, lexapro, daily vitamin
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Naproxen
Please list any allergies you may have and your bodies response to this allergy.	Zyrtec (hallucinations), hot sauce (anaphylaxis), latex (rash, anaphylaxis, itching)
What are your goals from physical therapy?	Less back pain
Please list a primary functional activity that you have difficulty performing.	House chores
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
Please list a second functional activity that you have difficulty performing.	Tending to children (bathing, dressing, etc)
How much difficulty do you have in performing this second 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:
Referral Source
How did you find out about us?	Other
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;	Hannah Sheridan
Signature