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)	Jeffrey Bernard McGee
Nickname/Name you liked to be called?	Jeff
Gender	Male
Date of Birth	04/08/1970
Address	940 Luckney Rd. Brandon, Mississippi 39047 Map It
Cell Phone	(601) 941-6309
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Oscar Other
Primary Insurance ID Number	OSC75158621-01
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?	No
Emergency Contacts
Emergency Contact 1: Name	LaToya McGee
Emergency Contact 1: Phone Number	(601) 953-4662
Basic Information
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	Aortic Valve Replacement
Did you have surgery?	Yes
Date of Surgery	04/08/2026
Surgical Procedure:	Aortic Valve Replacement
Living Situation	Lives with Family
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	30 years
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	Extremely
Please check or describe any limitations you have experienced in your Self Care:	Bathing Dressing Driving
Please check or describe any limitations you have experienced in your Mobility:	Use of Walking Aid(walker crutches cane...) Food Prep Housekeeping Laundry Transportation
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Transferring from Bed to Chair Transportation
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Fine Hand Use Pulling/Pushing Objects
Pain
Where is the location of your pain?	Chest
What is the WORST your pain gets on a 0 - 10 Scale?	9/10
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?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Sharp Throbbing
What makes your pain worse?	Coughing/Sneezing
What makes your pain better?	Medication
Employment
Are you employed?	Yes
Patient Employer	Self
Occupation	Lawn Care
Patient Employment Status	Full Time
Duty Level of Work:	Very Heavy
Are you currently working?	No
Off work since:	March
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Athanasios Tsiouris
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Cardiovascular Issues Diabetes Type 2 High Blood Pressure
Have you had any diagnostic imaging studies for this injury?	CT Scan
Have you had any recent or unexplained weight loss?	Yes
Are you taking any of the following?	Prescription Medications
What are your goals from physical therapy?	Strength/Walking Abilities
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;	LaToya McGee
Signature