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)	Sheri Renee Pickell
Nickname/Name you liked to be called?	Redd
Gender	Female
Date of Birth	05/21/1970
Email	Email hidden; Javascript is required.
Address	114 Alex Seal Ln Brandon, Mississippi 39042 Map It
Cell Phone	(601) 540-7649
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?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	75501069500
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Sheri Renee Pickell
Primary Insurance: Insured Party DOB	05/21/1970
Primary Insurance: Insured Address	114 Alex Seal Ln Brandon, Mississippi 39042 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	Deborah Lea
Emergency Contact 1: Phone Number	(601) 540-7650
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
Date of Injury or when your pain began.	07/12/2025
Is this injury due to:	Fall
Patient Maritial Status	Married
Briefly describe your symptoms:	Broken kneecap, three surgeries due to non union, I have had therapy once but had to stop due to the non union
How did your symptoms start?	Fell and broke the left kneecap half in two
What is your biggest complaint?	Leg is weak
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	Yes
Date of Surgery	12/17/2025
Surgical Procedure:	Put screws in the left kneecap
Rate your overall health:	Very Good
Home Layout	One Story Home
Living Situation	Lives with Family
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	20
On average, about how many packs per day did or do you smoke?	1
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	Extremely
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Bathing Chores Driving
Please check or describe any limitations you have experienced in your Mobility:	Food Prep Housekeeping Laundry Transportation Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Standing Kneeling Squatting Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Work/Vocation/Occupation Recreation Kicking/Pushing with Legs Pulling/Pushing Objects
Pain
Where is the location of your pain?	Left knee
What is the WORST your pain gets on a 0 - 10 Scale?	4/10
What is the BEST your pain gets on a 0 - 10 Scale?	1/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	1/10
Pain Description (Please check all that apply)	Sharp Dull/Achy Numbness/Tingling
What makes your pain worse?	Standing Walking Going Up Stairs Going Down Stairs Standing Bending
What makes your pain better?	Not using the knee too much
Employment
Are you employed?	Yes
Patient Employer	Omega Cannabis
Occupation	Logistics/Inventory Manager
Patient Employment Status	Full Time
Duty Level of Work:	Heavy
Are you currently working?	No
Off work since:	11/2025
Patient Employer Address	540 Ford Ave Building B Jackson, Mississippi 39209 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Austin Barrett
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 Vitamin/Mineral/Dietary Supplements
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Zoloft. Xanax, Rosuvastatin, Levothyroxine, Tizanidine, 81mg aspirin
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Multi vitamin, vitamin d, vitamin c
Please list any allergies you may have and your bodies response to this allergy.	Neosporin-rash
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Total hysterectomy, colon resection, gallbladder, splenectomy, breast reduction, left knee, right ear, gastric sleeve
What are your goals from physical therapy?	To strengthen my leg, get full flexion and walk normally
Please list a primary functional activity that you have difficulty performing.	Bending my knee
How much difficulty do you have in performing this first task?	0/10 - Unable to Perform
Please list a second functional activity that you have difficulty performing.	Walking without limp
How much difficulty do you have in performing this second task?	3/10
Please list a third functional activity that you have difficulty performing.	Weakness in quad
How much difficulty do you have in performing this third task?	2/10
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:
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;	Renee Pickell
Signature