Online Admission Form - Reliant Physical Therapy

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Date	04/23/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Janie Wallace Ferguson
Nickname/Name you liked to be called?	Janie
Gender	Female
Date of Birth	08/30/1953
Email	Email hidden; Javascript is required.
Address	2180 Attala Road 1183 Kosciusko, Mississippi 39090 Map It
Home Phone	(601) 663-6782
Which clinic will you receive treatment at?	Kosciusko
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Humana
Primary Insurance ID Number	H66559954
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Address	2180 Attala Road 1183 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	Les Ferguson
Emergency Contact 1: Phone Number	(601) 562-4226
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back Hip Right Knee
What side of the body will we be treating?	Back
Date of Injury or when your pain began.	06/15/2024
Patient Maritial Status	Married
Briefly describe your symptoms:	Severe back and spine pain goes to right hip down to feet causing neuropathy
What is your biggest complaint?	Back
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent Good
Home Layout	One Story Home Shower Stall Combo Tub/Shower
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?	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 Self Care:	Chores
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home Housekeeping Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Standing Kneeling Transferring from Bed to Chair Housekeeping
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Kicking/Pushing with Legs Pulling/Pushing Objects
Pain
Where is the location of your pain?	Back
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?	8/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	8/10
Pain Description (Please check all that apply)	Numbness/Tingling Constant Worse in AM
What makes your pain worse?	Standing Walking Going Up Stairs Going Down Stairs Bending Lying Down Coughing/Sneezing
What makes your pain better?	Nothing really
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Jeffrey Lassitor
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Obesity
Have you had any diagnostic imaging studies for this injury?	CT Scan
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Other
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Multi Vitamin and B 12 shot
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Spinal cord stimulator
What are your goals from physical therapy?	Ease the pain
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?	Other
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;	Janie Ferguson
Signature