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)	Kristin Lynette Strader
Nickname/Name you liked to be called?	Kristin
Gender	Female
Date of Birth	03/25/1970
Email	Email hidden; Javascript is required.
Address	509 Ridge Circle Brandon, Mississippi 39047 Map It
Cell Phone	(864) 985-3301
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	YAX869215153M
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Kristin Lynette Strader
Primary Insurance: Insured Party DOB	03/25/1970
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	509 Ridge Circle 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	Ken Strader
Emergency Contact 1: Phone Number	(864) 985-9508
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Achilles, ankle, hip
What side of the body will we be treating?	Both
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	Achilles stiff since November. Now have Achilles tendinitis Hip sore since June.
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	Two 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	A Little Bit
Pain
Where is the location of your pain?	Achilles and left hip and leg
What is the WORST your pain gets on a 0 - 10 Scale?	6/10
What is the BEST your pain gets on a 0 - 10 Scale?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Dull/Achy
What makes your pain worse?	Walking
What makes your pain better?	Staying off of it
Employment
Are you employed?	Yes
Patient Employer	Rankin County School District
Occupation	Teacher
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	1220 Apple Park Place Brandon Mississippi 39042 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Daniel J. Ross
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 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.	Valtrex, azelastine hydrochloride nasal spray
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Allegra, Flonase daily
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Women’s vitamins daily
Please list any allergies you may have and your bodies response to this allergy.	Sulfa, pollen, dander, grass
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Ovaries removed - June 2025, hysterectomy - 2017, right ankle surgery 2007
What are your goals from physical therapy?	Better mobility, better flexibility, no more pain
Please list a primary functional activity that you have difficulty performing.	Stretching
How much difficulty do you have in performing this first task?	8/10
Please list a second functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this second task?	8/10
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?	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;	Kristin Strader
Signature