Online Admission Form - Reliant Physical Therapy

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Date	03/01/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Lana Elizabeth Mudd
Nickname/Name you liked to be called?	Beth
Gender	Female
Date of Birth	05/06/1964
Email	Email hidden; Javascript is required.
Address	106 Stonington Court Brandon, Mississippi 39047 Map It
Cell Phone	(601) 842-4377
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: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Lana Elizabeth Mudd
Primary Insurance: Insured Party DOB	05/06/1964
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	106 Stonington Court 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	Gary Mudd
Emergency Contact 1: Phone Number	(601) 209-6629
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Strengthen
What side of the body will we be treating?	Legs
Patient Maritial Status	Married Divorced
Briefly describe your symptoms:	Weakness in lower extremities.
How did your symptoms start?	Gradually
What is your biggest complaint?	Strength
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 Shower Stall
Living Situation	Lives with Family
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	No longer smoking.
On average, about how many packs per day did or do you smoke?	1
Do you have a history of falling?	Yes
How many falls have you had in the past year?	4-5 ish
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	Quite a Bit
Please check or describe any limitations you have experienced in your Mobility:	Housekeeping Negotiating Obstacles Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Kneeling Squatting Housekeeping
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Kicking/Pushing with Legs Pulling/Pushing Objects
Pain
Where is the location of your pain?	Lower back
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?	0/10 - No Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	0/10 - No Pain
Pain Description (Please check all that apply)	Throbbing Shooting Numbness/Tingling
What makes your pain worse?	Sitting Standing Standing
What makes your pain better?	Rest
Employment
Are you employed?	Yes
Patient Employer	MBAH
Occupation	Accounting/Procurement
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	121 N Jefferson St Jackson, Mississippi 39201 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Amanda Green
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Lupus Other
Have you had any diagnostic imaging studies for this injury?	MRI
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 Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Aspirin Multivitamin
Please list any allergies you may have and your bodies response to this allergy.	Seafood
What are your goals from physical therapy?	Strengthen legs
Please list a primary functional activity that you have difficulty performing.	Squatting
How much difficulty do you have in performing this first task?	0/10 - Unable to Perform
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?	Doctor
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;	Lana Mudd
Signature