Online Admission Form - Reliant Physical Therapy

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Date	03/10/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Carla Elizabeth Morgan
Nickname/Name you liked to be called?	Oliver
Gender	Female
Date of Birth	01/26/2000
Address	132 Westlake Drive Brandon, Mississippi 39047 Map It
Cell Phone	(601) 813-8998
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	Ambetter
Primary Insurance ID Number	U9522152801
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Carla Elizabeth Morgan
Primary Insurance: Insured Party DOB	01/26/2000
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	132 Westlake Drive Brandon, Mississippi 39047 Map It
Do you have a secondary Insurance.	Yes
Secondary Insurance	Mississippi Medicaid
Secondary Insurance ID Number	905002023
Secondary Insurance: Patient's Relationship to Insured Party	Self
Secondary Insurance: Insured Party DOB	01/26/2000
Secondary Insurance: Insured Address	132 Westlake Drive Brandon, Mississippi 39047 Map It
Emergency Contacts
Emergency Contact 1: Name	Cynthia Morgan
Emergency Contact 1: Phone Number	(601) 953-1475
Basic Information
Is this injury due to:	Other
Patient Maritial Status	Single
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Fair
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	Moderately
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Chores
Please check or describe any limitations you have experienced in your Mobility:	Use of Walking Aid(walker crutches cane...) Food Prep 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 Housekeeping
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Work/Vocation/Occupation Recreation Kicking/Pushing with Legs
Pain
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?	4/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	4/10
Pain Description (Please check all that apply)	Sharp Shooting Constant
What makes your pain worse?	Standing Walking Going Up Stairs Going Down Stairs Standing
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Kelli Cranford, NP
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Other
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Scopolamine, Omeprazole 40mg, amitriptyline 25, Emgality 120mg/ml, Mirtazapine 30mg, Zofran 8mg, Symbicort 160-4.5 mcg, Spiriva 1.25 mcg, Famotidine 40mg, Cyanocobalamin 1000 mcg/ml, albuterol nebulizer, albuterol inhaler, Metoprolol 25, Florinef 0.2mg
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	asprin 81mg, Tylenol
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	chest reconstruction July 12, 2017
Please list a primary functional activity that you have difficulty performing.	Walking for more than a few minutes
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;	Carla Morgan
Signature