Online Admission Form - Reliant Physical Therapy

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Date	05/20/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Justin McDonald
Gender	Male
Date of Birth	06/06/1994
Email	Email hidden; Javascript is required.
Address	133 Belaire Dr Pearl, Mississippi 39208 Map It
Home Phone	(601) 259-1306
Cell Phone	(832) 797-1462
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	907971515
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Nataley McDonald
Primary Insurance: Insured Party DOB	06/13/1999
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	133 Belaire 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
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Right leg
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	04/07/2026
Is this injury due to:	Sports Related
Patient Maritial Status	Married
Briefly describe your symptoms:	Broken leg right above ankle
How did your symptoms start?	Sports injury
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	Yes
Date of Surgery	04/15/2026
Surgical Procedure:	Lower leg surgery
Rate your overall health:	Good
Home Layout	One Story Home
Living Situation	Lives with Family
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	10
On average, about how many packs per day did or do you smoke?	1/2
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:	Sleeping Bathing Driving
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home Transportation
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Kneeling Squatting Transportation
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Kicking/Pushing with Legs
Pain
Where is the location of your pain?	Right leg
What is the WORST your pain gets on a 0 - 10 Scale?	7/10
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?	3/10
Pain Description (Please check all that apply)	Burning Throbbing Constant
What makes your pain worse?	Standing Walking
What makes your pain better?	Resting
Employment
Are you employed?	Yes
Patient Employer	Movemint
Occupation	Crew Lead
Patient Employment Status	Out of Work
Duty Level of Work:	Heavy
Are you currently working?	No
Off work since:	4/8/26
Patient Employer Address	Mississippi Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Penny Lawin
Medical History
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?	Over the Counter Medications
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Ibuprofen
Please list any allergies you may have and your bodies response to this allergy.	Penicillin
What are your goals from physical therapy?	Walk
Please list a primary functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this first task?	1/10
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;	Justin McDonald
Signature