Online Admission Form - Reliant Physical Therapy

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Date	04/24/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Virginia Perry Lewis
Gender	Female
Date of Birth	02/16/1978
Email	Email hidden; Javascript is required.
Address	158 Sycamore Ridge Madison, Mississippi 39110 Map It
Cell Phone	(601) 573-7837
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	No Insurance - Self Pay
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	19976364
Case Worker/Adjustor's Name:	Maria Hays
Case Worker/Adjustor's Phone Number	(689) 256-2121
Emergency Contacts
Emergency Contact 1: Name	Jerry Lewis
Emergency Contact 1: Phone Number	(601) 906-2118
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back
What side of the body will we be treating?	Back
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?	Florida
Patient Maritial Status	Married
Briefly describe your symptoms:	Back pain and spasms
How did your symptoms start?	03/16/2026
What is your biggest complaint?	Back pain
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
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	A Little Bit
Pain
Where is the location of your pain?	Back
What is the WORST your pain gets on a 0 - 10 Scale?	6/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Sharp Dull/Achy Shooting
What makes your pain worse?	Sitting Lying Down
What makes your pain better?	Pain med/ Muscle relaxer
Employment
Are you employed?	Yes
Patient Employer	MSH
Occupation	Nurse Practitioner
Patient Employment Status	Full Time
Duty Level of Work:	Light
Are you currently working?	Yes - Regular Duty
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Sarabeth Clark, FNP
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?	X-Ray
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Vitamin/Mineral/Dietary Supplements
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Motrin
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Multivitamins
Please list any allergies you may have and your bodies response to this allergy.	None
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Cesarean x 2, gallbladder removed
What are your goals from physical therapy?	Assist with pain relief
Please list a primary functional activity that you have difficulty performing.	None
How much difficulty do you have in performing this first task?	10/10 - No Problem or Difficulty Performing
How much difficulty do you have in performing this second task?	10/10 - No Problem or Difficulty Performing
How much difficulty do you have in performing this third task?	10/10 - No Problem or Difficulty Performing
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?	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;	Virginia Lewis
Signature