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)	Paul Raymond Wilson
Gender	Male
Date of Birth	03/20/1967
Address	107 Garden View Dr. Brandon, Mississippi 39047 Map It
Home Phone	(601) 992-9569
Cell Phone	(601) 622-0913
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	United HealthCare
Primary Insurance ID Number	41671638
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Paul Raymond Wilson
Primary Insurance: Insured Party DOB	03/20/1967
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	107 Garden View 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	Nancy Shropshire
Emergency Contact 1: Phone Number	(601) 992-9569
Emergency Contact 2: Name	Jen Jones
Emergency Contact 2: Phone Number	(601) 953-0121
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back, leg, hip
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	11/01/2025
Is this injury due to:	Other
Patient Maritial Status	Divorced
Briefly describe your symptoms:	thigh and leg pain shifting different places when walking. Back tightness.
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	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:	Chores
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home
Pain
Where is the location of your pain?	left leg
What is the WORST your pain gets on a 0 - 10 Scale?	7/10
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?	6/10
Pain Description (Please check all that apply)	Throbbing Shooting Intermittent
What makes your pain worse?	Walking
Employment
Are you employed?	Yes
Patient Employer	ISO Services
Occupation	Material Sale Manager
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	1625 Flowood Dr. Flowood, Mississippi 39232 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Jeffrey Scott Harrison
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.	Diclofenac Sodium
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Advil PM
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Multi-Vitamin
What are your goals from physical therapy?	stop the pain
Please list a primary functional activity that you have difficulty performing.	walking
How much difficulty do you have in performing this first task?	3/10
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;	Paul Wilson
Signature