Online Admission Form - Reliant Physical Therapy

← Go back

Date	03/02/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Jereme Devon Tucker
Nickname/Name you liked to be called?	Jay
Gender	Male
Date of Birth	11/22/1983
Email	Email hidden; Javascript is required.
Address	336 E South Street Kosciusko, Mississippi 39090 Map It
Cell Phone	(662) 630-0205
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	VA Consult
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Jereme D Tucker
Primary Insurance: Insured Party DOB	11/22/1983
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	336 E South Street Kosciusko, Mississippi 39090 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	Mary Windrick
Emergency Contact 1: Phone Number	(662) 323-1670
Emergency Contact 2: Name	Michael Ward
Emergency Contact 2: Phone Number	(166) 257-4375
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Knee, leg
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	12/16/2025
Is this injury due to:	Unknown
Patient Maritial Status	Single
Briefly describe your symptoms:	I started having knee pain the latter part of last year, but when it lead to numbness I grew more concerned and saw a doctor. The doctor advised the pain seemed to be related to the peroneal nerve.
How did your symptoms start?	A light, intermittent knee pain
What is your biggest complaint?	Inability to bend and numbness
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	One Story Home Combo Tub/Shower
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	A Little Bit
Please check or describe any limitations you have experienced in your Self Care:	Dressing Chores Driving
Please check or describe any limitations you have experienced in your Mobility:	Housekeeping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Kneeling Squatting
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Recreation Kicking/Pushing with Legs
Pain
Where is the location of your pain?	Knee
What is the WORST your pain gets on a 0 - 10 Scale?	8/10
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?	3/10
Pain Description (Please check all that apply)	Throbbing Numbness/Tingling Intermittent
What makes your pain worse?	Sitting Bending
What makes your pain better?	Heat pad
Employment
Are you employed?	Yes
Patient Employer	Trustmark Bank
Occupation	Collateral Tracking Specialist
Patient Employment Status	Full Time
Duty Level of Work:	Very Light
Are you currently working?	Yes - Regular Duty
Patient Employer Address	201 Country Place Pkwy Pearl, Mississippi 39208 Map It
Are you disabled or currently on disability?	No
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Obesity Other
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.	Eye drops for glaucoma
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Aspirin
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	N/a
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	Ginger lemon tea
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Vitamin C, probiotics
Please list the Other medications you are taking. You may bring in a list if you prefer to do so.	N/a
Please list any allergies you may have and your bodies response to this allergy.	N/a
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Right foot—August 2025
What are your goals from physical therapy?	To eliminate the pain and gain flexibility.
Please list a primary functional activity that you have difficulty performing.	Exercising, driving, household chores
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
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;	Jereme Tucker
Signature