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)	Sean Martel Bowie
Gender	Male
Date of Birth	07/21/1987
Email	Email hidden; Javascript is required.
Address	17640 Williamsville Road Kosciusko, Mississippi 39090 Map It
Home Phone	(601) 850-9408
Which clinic will you receive treatment at?	Kosciusko
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Medicare
Primary Insurance ID Number	5A07-RP3-QJ65
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Sean Martel Bowie
Primary Insurance: Insured Party DOB	07/21/1987
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	17640 Williamsville Road Kosciusko, Mississippi 39090 Map It
Do you have a secondary Insurance.	Yes
Secondary Insurance	Medicaid
Secondary Insurance ID Number	364286589
Secondary Insurance: Patient's Relationship to Insured Party	Self
Secondary Insurance: Insured Party DOB	07/21/1987
Secondary Insurance: Insured Party Gender	Male
Secondary Insurance: Insured Address	17640 Williamsville Road Kosciusko, Mississippi 39090 Map It
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Daphne Bowie
Emergency Contact 1: Phone Number	(601) 940-1462
Emergency Contact 2: Name	Patricia Bowie
Emergency Contact 2: Phone Number	(601) 900-9206
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Right leg and ankle
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	10/12/2024
Is this injury due to:	Picking up something
Patient Maritial Status	Divorced
Briefly describe your symptoms:	I went to pick up something I slipped my L4-5 right side had surgery to try to get full feeling and motion back but I got some feeling back in it but very little and very little motion in my ankle. I’ve had three back surgeries so my L4-5 left has already been operated on as well so I have very little disc left. They want to do a fusion on me, but we didn’t go that route because we were trying to save the nerve in my leg. I have limited filling and drop foot I cannot flex my toes all on my right side from the knee down
How did your symptoms start?	When my disk bulged, my leg, went on all at the same time then when I stepped into the bathtub, it got worse
What is your biggest complaint?	Having foot drop and pain I wanna try to get feeling back if I use a leg too much I get this horrible pain. It feels like it’s down in the bone between my ankle and my knee.
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	Yes
Date of Surgery	10/15/2024
Surgical Procedure:	microdiscectomy
Rate your overall health:	Good Fair
Living Situation	Lives Alone
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	20
On average, about how many packs per day did or do you smoke?	1
Do you have a history of falling?	Yes
How many falls have you had in the past year?	2
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:	Sleeping Chores Driving
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home Use of Walking Aid(walker crutches cane...) Housekeeping Laundry Transportation Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Standing Kneeling Squatting Transferring from Bed to Chair Housekeeping Transportation
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?	Right leg between ankle and knee
What is the WORST your pain gets on a 0 - 10 Scale?	8/10
What is the BEST your pain gets on a 0 - 10 Scale?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	2/10
Pain Description (Please check all that apply)	Burning Sharp Dull/Achy Shooting Numbness/Tingling Constant Worse in PM
What makes your pain worse?	Standing Walking Going Up Stairs Going Down Stairs Standing
What makes your pain better?	Rest
Employment
Are you employed?	No
Are you disabled or currently on disability?	Yes
When did you become disabled or on disability?	2021
What is the reason you are disabled?	Obesity and back
What doctor referred you to therapy?	Walker
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Obesity Fibromyalgia
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?	Vitamin/Mineral/Dietary Supplements
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Losartan Crestor naproxen
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	MiraLAX
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Bariatric vitamins
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Three back surgeries, two hernia surgeries
What are your goals from physical therapy?	Try to get motion and filling back in my right foot and ankle
Please list a primary functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
Please list a second functional activity that you have difficulty performing.	Standing for long periods
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?	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;	Sean Bowie
Signature