Online Admission Form - Reliant Physical Therapy

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Date	02/25/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Molina healthcare Madison Travis
Nickname/Name you liked to be called?	Maddie
Gender	Female
Date of Birth	12/31/2008
Address	103 oak park dr Pearl, Mississippi 39206 Map It
Cell Phone	(601) 791-2813
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Guarantor Name	Travis
Guarantor Gender	Female
Guarantor Address	Mississippi Map It
Insurance Information
Primary Insurance	Molina
Primary Insurance ID Number	853170429
Primary Insurance: Insured Party Name	Molina healthcare Madison Travis
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	Mississippi 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	Mamie Travis
Emergency Contact 1: Phone Number	(601) 901-7134
Emergency Contact 2: Name	Keonna Lewis
Emergency Contact 2: Phone Number	(601) 540-0248
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Knee
What side of the body will we be treating?	Left
Is this injury due to:	Fall
Patient Maritial Status	Single
Briefly describe your symptoms:	Knee pops every blue moon and cause a lot of pain
How did your symptoms start?	Knee just popped one day
What is your biggest complaint?	The pain
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
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	Not at All
Pain
Where is the location of your pain?	Left knee
What is the WORST your pain gets on a 0 - 10 Scale?	9/10
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?	0/10 - No Pain
What makes your pain worse?	Standing
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dillon Pankey
Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	N/A
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	N/A
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	N/A
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	N/A
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	N/A
Please list the Other medications you are taking. You may bring in a list if you prefer to do so.	N/A
Please list any allergies you may have and your bodies response to this allergy.	N/A
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	N/A
What are your goals from physical therapy?	To make my knee stronger
Please list a primary functional activity that you have difficulty performing.	N/A
How much difficulty do you have in performing this first task?	10/10 - No Problem or Difficulty Performing
How much difficulty do you have in performing this second task?	10/10 - No Problem or Difficulty Performing
How much difficulty do you have in performing this third task?	10/10 - No Problem or Difficulty Performing
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?	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;	Deonna Travis
Signature