Online Admission Form - Reliant Physical Therapy

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Date	04/10/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Noah Watts Butler
Gender	Male
Date of Birth	03/29/2012
Email	Email hidden; Javascript is required.
Address	156 Westlake Drive Brandon, Mississippi 39047 Map It
Home Phone	(769) 234-0111
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Ashley Butler
Guarantor Gender	Female
Guarantor Date of Birth	09/15/1988
Guarantor Phone	(769) 234-0111
Guarantor Address	156 Westlake Drive Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	ChampVA
Primary Insurance ID Number	794536507
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Noah Butler
Primary Insurance: Insured Party DOB	03/29/2012
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	156 Westlake Drive 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	Ashley Butler
Emergency Contact 1: Phone Number	(769) 234-0111
Emergency Contact 2: Name	Andrew Butler
Emergency Contact 2: Phone Number	(601) 954-8677
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Leg
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	12/01/2025
Is this injury due to:	Sports Related
Patient Maritial Status	Single
Briefly describe your symptoms:	Stress fracture
How did your symptoms start?	Pain when playing sports
What is your biggest complaint?	Bottom of feet hurt. Weak leg
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	Two 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
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Kicking/Pushing with Legs
Pain
Where is the location of your pain?	Feet
What is the WORST your pain gets on a 0 - 10 Scale?	10/10 - Severe Pain
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?	6/10
Pain Description (Please check all that apply)	Sharp Dull/Achy Constant
What makes your pain worse?	Walking
What makes your pain better?	Sitting
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr. Boston
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?	MRI
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Over the Counter Medications
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Vit D.
What are your goals from physical therapy?	Get back to playing soccer
Please list a primary functional activity that you have difficulty performing.	Household chores.
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.	Playing soccer
How much difficulty do you have in performing this second 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.
Referral Source
How did you find out about us?	Mother was prior patient
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;	Ashley Butler
Signature