Online Admission Form - Reliant Physical Therapy

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Date	02/23/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Randall Boykin
Nickname/Name you liked to be called?	Randall
Gender	Male
Date of Birth	05/29/1957
Email	Email hidden; Javascript is required.
Address	92 Woodlands green dr Brandon, Mississippi 39047 Map It
Cell Phone	(601) 832-4199
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	Wellcare
Primary Insurance ID Number	31898367
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Randall Boykin
Primary Insurance: Insured Party DOB	05/29/1957
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	92 Woodlands green dr Brandon, Mississippi 39047 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	Aileen Boykin
Emergency Contact 1: Phone Number	(601) 317-0410
Basic Information
What side of the body will we be treating?	Neck
Date of Injury or when your pain began.	01/20/2026
Patient Maritial Status	Married
Briefly describe your symptoms:	Pain left side of neck,shoulder very numb front of shoulder and chest ,back of shoulder and neck
How did your symptoms start?	No reason
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:	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?	No
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
Please check or describe any limitations you have experienced in your Mobility:	Housekeeping Laundry Negotiating Obstacles Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Transferring from Bed to Chair
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Pulling/Pushing Objects
Pain
Where is the location of your pain?	Neck and shoulder
What is the WORST your pain gets on a 0 - 10 Scale?	5/10 - Moderate Pain
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)	Burning Sharp Dull/Achy Throbbing Shooting Numbness/Tingling Constant
What makes your pain worse?	Sitting Standing Walking Going Up Stairs Going Down Stairs Standing Bending
What makes your pain better?	When not moving
Employment
Are you employed?	No
What doctor referred you to therapy?	Hoffmann
Medical History
Have you had any diagnostic imaging studies for this injury?	MRI
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Rosuvastatin,tamaulosin,gabapentin,sildenafil,diclofenac,zolpidem
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Aleve
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	none
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	None
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	None
Please list the Other medications you are taking. You may bring in a list if you prefer to do so.	None
Please list any allergies you may have and your bodies response to this allergy.	none
What are your goals from physical therapy?	To get well
Please list a primary functional activity that you have difficulty performing.	Moving my left arm
How much difficulty do you have in performing this first task?	10/10 - No Problem or Difficulty Performing
Please list a second functional activity that you have difficulty performing.	Turning my head
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.	Getting out of bed and car
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:
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;	Randall Boykin
Signature