Online Admission Form - Reliant Physical Therapy

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Date	05/22/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Grace Elisabeth Hayes
Nickname/Name you liked to be called?	Gracie
Gender	Female
Date of Birth	10/20/2008
Email	Email hidden; Javascript is required.
Address	223 Bay park dr Brandon, Mississippi 39047 Map It
Cell Phone	(407) 402-3623
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Bret Michael Hudson
Guarantor Gender	Male
Guarantor Date of Birth	09/11/1981
Guarantor Phone	(407) 655-7781
Guarantor Address	223 Bay park dr Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	United HealthCare
Primary Insurance ID Number	771900652971
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	Bret Michael Hudson
Primary Insurance: Insured Party DOB	09/11/1981
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(407) 655-7781
Primary Insurance: Insured Address	223 Bay park dr Brandon, Mississippi 39047 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	Susanne Hudson
Emergency Contact 1: Phone Number	(407) 402-3623
Emergency Contact 2: Name	Bret Hudson
Emergency Contact 2: Phone Number	(407) 655-7781
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Wrist, and knees
What side of the body will we be treating?	Both
Patient Maritial Status	Single
Briefly describe your symptoms:	She will just get pains in these area. This recently started. It hurts a lot in the wrist. When she wakes up a lot of times her hands are really tight. Her knees seem to maybe move to much or pop also when she gets up
How did your symptoms start?	Just started hurting
What is your biggest complaint?	Pain
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Very Good
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?	Wrist and knees
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?	0/10 - No Pain
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Burning Dull/Achy Throbbing Numbness/Tingling
What makes your pain worse?	Walking Bending
Employment
Are you employed?	Yes
Patient Employer	Little Ceasers
Patient Employment Status	Part Time
Duty Level of Work:	Medium
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?	Monica Lonbins. DO
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Other
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Na
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	Na
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	Na
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Na
Please list the Other medications you are taking. You may bring in a list if you prefer to do so.	Na
Please list any allergies you may have and your bodies response to this allergy.	Na
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Na
What are your goals from physical therapy?	To have no pain
Please list a primary functional activity that you have difficulty performing.	I can still do whatever just might hurt
How much difficulty do you have in performing this first task?	7/10
How much difficulty do you have in performing this second task?	8/10
How much difficulty do you have in performing this third task?	8/10
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?	You are across from her work
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;	Susanne Hudson
Signature