Online Admission Form - Reliant Physical Therapy

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Date	04/14/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Lushandia Nicole Hart
Nickname/Name you liked to be called?	Shanda
Gender	Female
Date of Birth	02/22/1972
Email	Email hidden; Javascript is required.
Address	3345 Patterson Dr Pearl, Mississippi 39208 Map It
Cell Phone	(601) 916-1573
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Humana
Primary Insurance ID Number	H62833806
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Address	Mississippi Map It
Do you have a secondary Insurance.	No
Is this a worker's compensation or other accident claim?	Yes
Claim Number	26-902705572
Case Worker/Adjustor's Name:	Sarkisha Williams
Case Worker/Adjustor's Phone Number	(601) 329-2595
Emergency Contacts
Emergency Contact 1: Name	Terrieonna Hart
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Hip, thigh,knee and leg
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	03/15/2026
Is this injury due to:	Motor Vehicle Accident
What state did the MVA occur in?	Mississippi
Patient Maritial Status	Single
Briefly describe your symptoms:	Having stiffness and pain radiating down left side.
How did your symptoms start?	I woke up the next morning could barely walk leg was real stiff the pain has been like having a Charlie horse down my whole left leg.
What is your biggest complaint?	Stiffness and discomfort
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?	Yes
How many years did or have you smoked?	10
On average, about how many packs per day did or do you smoke?	1
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:	Sleeping
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 Change and Move Body Positions:	Prolonged Standing Kneeling Squatting
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Recreation
Pain
Where is the location of your pain?	Hip, thigh, knee and 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?	5/10 - Moderate Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	7/10
Pain Description (Please check all that apply)	Sharp Dull/Achy Throbbing Shooting
What makes your pain worse?	Standing Walking Going Up Stairs Going Down Stairs Standing
What makes your pain better?	Medication and soaking in Epsom salt baths
Employment
Are you employed?	No
Are you disabled or currently on disability?	Yes
When did you become disabled or on disability?	2009
What is the reason you are disabled?	Multiple Sclerosis
Medical History
Do you have any of the following medical conditions? (Check all that apply)	History of Cancer Cardiovascular Issues
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Oxycodone, Metformin, Losartan, Clonidine, Metoprolol, Mounjaro, Xanax,
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	325 Bayer Aspirin
Please list the Other medications you are taking. You may bring in a list if you prefer to do so.	Omeprazol
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.)	Femur and foot surgery, Hysterectomy, Lump removed from left breast , Removal of tumor from chest
What are your goals from physical therapy?	To be pain free from left sidd
Please list a primary functional activity that you have difficulty performing.	Walking and stiffness in my sleep and when waking up
How much difficulty do you have in performing this first task?	6/10
Please list a second functional activity that you have difficulty performing.	Bothers me sitting at times
How much difficulty do you have in performing this second task?	5/10 - Moderate Difficulty
How much difficulty do you have in performing this third task?	7/10
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?	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;	Lushandia Hart
Signature