Online Admission Form - Reliant Physical Therapy

← Go back

Date	04/30/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Lydia Lotus Shoemake
Nickname/Name you liked to be called?	Lydia
Gender	Female
Date of Birth	08/31/1979
Email	Email hidden; Javascript is required.
Address	109 skylane dr Pearl, Mississippi 39208 Map It
Home Phone	(714) 454-4232
Cell Phone	(714) 454-4232
Work Phone	(601) 292-4571
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Blus cross blue shield of Tennessee
Primary Insurance ID Number	IOB908185979
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Lydia L Shoemake
Primary Insurance: Insured Party DOB	08/31/1979
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	109 skylane dr Pearl, Mississippi 39208 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	Tara Sebren
Emergency Contact 1: Phone Number	(601) 695-1244
Emergency Contact 2: Name	Robert Shoemake
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Right knee
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	02/28/2026
Is this injury due to:	Other
Patient Maritial Status	Single
Briefly describe your symptoms:	Pain on right side and back od knee. Pain from side of hip radiating to foot
How did your symptoms start?	After lifting wheelchair over threshold
What is your biggest complaint?	Knee pain
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	One Story Home 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?	No
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Moderately
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Caregiving
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Kneeling Squatting Housekeeping Laundry
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 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?	3/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Dull/Achy Constant Worse at night while sleeping
What makes your pain worse?	Sitting Standing Walking Going Up Stairs Bending Lying Down
What makes your pain better?	Medicine helps dull the pain
Employment
Are you employed?	Yes
Patient Employer	Baptist hospital
Occupation	Admissions representative
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	1225 north state street Jackson, Mississippi 39202 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr.Craft
Medical History
Do you have any of the following medical conditions? (Check all that apply)	History of Cancer Diabetes Type 2 Obesity High Blood Pressure
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 any allergies you may have and your bodies response to this allergy.	Codeine and sulfa
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Left knee acl reconstruction 4/2024, abdominal surgery 2025,hysterectomy 8/2022
What are your goals from physical therapy?	Strengthening and no pain
Please list a primary functional activity that you have difficulty performing.	Bending to lift paper boxes
How much difficulty do you have in performing this first task?	0/10 - Unable to Perform
Please list a second functional activity that you have difficulty performing.	Walking up and down steps
How much difficulty do you have in performing this second task?	5/10 - Moderate Difficulty
Please list a third functional activity that you have difficulty performing.	Sitting longer than a hour
How much difficulty do you have in performing this third 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?	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;	Lydia Shoemake
Signature