Online Admission Form - Reliant Physical Therapy

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Date	02/26/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Deborah S Hollingsworth
Nickname/Name you liked to be called?	Debbie
Gender	Female
Date of Birth	03/03/1955
Email	Email hidden; Javascript is required.
Address	780 Benwick Drive, Mississippi 39047 Map It
Cell Phone	(601) 672-3373
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	Medicare
Primary Insurance ID Number	2K82-R07-PY06
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Deborah S Hollingsworth
Primary Insurance: Insured Party DOB	03/03/1955
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	780 Benwick Drive, Mississippi 39047 Map It
Do you have a secondary Insurance.	Yes
Secondary Insurance	United world lif ins
Secondary Insurance ID Number	853159-94
Secondary Insurance: Patient's Relationship to Insured Party	Self
Secondary Insurance: Insured Phone	(601) 672-3373
Secondary Insurance: Insured Party DOB	03/03/1955
Secondary Insurance: Insured Party Gender	Female
Secondary Insurance: Insured Address	780 Benwick Drive, Mississippi 39047 Map It
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Rita Parker
Emergency Contact 1: Phone Number	(601) 209-5792
Emergency Contact 2: Name	Leigh Moore
Emergency Contact 2: Phone Number	(601) 896-8045
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?	Right
Date of Injury or when your pain began.	02/02/2026
Patient Maritial Status	Other
Briefly describe your symptoms:	Pain. soreness
How did your symptoms start?	Bone on bone
What is your biggest complaint?	Pain
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	Yes
Date of Surgery	02/02/2026
Surgical Procedure:	Knee replacement
Rate your overall health:	Good
Living Situation	Lives Alone
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 Chores Driving
Pain
Where is the location of your pain?	Knee
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?	0/10 - No Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	2/10
Pain Description (Please check all that apply)	Sharp Shooting Numbness/Tingling Worse in AM
What makes your pain worse?	Walking Standing Bending Lying Down
What makes your pain better?	Moving, therapy ice rest
Employment
Are you employed?	Yes
Patient Employer	Self
Occupation	Cosmetologist
Patient Employment Status	Part Time
Duty Level of Work:	Medium
Are you currently working?	No
Off work since:	January 31
Patient Employer Address	780 Benwick Drive Brandon, Mississippi 39047 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Merhle’
Medical History
Do you have any of the following medical conditions? (Check all that apply)	History of Cancer Diabetes Type 2 Osteoarthritis High Blood Pressure
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 Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Aspirin stool softener CoQ10 calcium Vitamin D
Please list any allergies you may have and your bodies response to this allergy.	Novacaine swelling
What are your goals from physical therapy?	Be normal without pain
Please list a primary functional activity that you have difficulty performing.	Getting out of bed, off a chair, rolling over in bed
Are you currently receiving home health services?	Yes
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
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;	Debbie Hollingsworth
Signature