Online Admission Form - Reliant Physical Therapy

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Date	05/26/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Barbara J Bither
Gender	Female
Date of Birth	06/03/1962
Email	Email hidden; Javascript is required.
Address	96 A Village Dr Brandon, Mississippi 39047 Map It
Cell Phone	(931) 257-0955
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Spouse
Guarantor Name	Randy A Bither
Guarantor Gender	Male
Guarantor Date of Birth	01/01/1963
Guarantor Phone	(601) 624-8746
Guarantor Address	96 A Village Dr Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	Ambetter
Primary Insurance ID Number	U7019874402
Primary Insurance: Patient's Relationship to Insured Party	Spouse
Primary Insurance: Insured Party Name	Randy A Bither
Primary Insurance: Insured Party DOB	01/01/1963
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(601) 624-8746
Primary Insurance: Insured Address	96 A Village 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	Randy Bither
Emergency Contact 1: Phone Number	(601) 624-8746
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Shoulder
What side of the body will we be treating?	Left
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	Pain and stiffness
How did your symptoms start?	Just started getting worse
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Home Layout	One Story Home Shower Stall
Living Situation	Lives with Family
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?	2
Do you have a history of falling?	Yes
How many falls have you had in the past year?	0
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
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Dressing Chores
Please check or describe any limitations you have experienced in your Mobility:	Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Pulling/Pushing Objects
Pain
Where is the location of your pain?	L shoulder
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?	0/10 - No Pain
Pain Description (Please check all that apply)	Dull/Achy Throbbing Worse at night while sleeping
What makes your pain worse?	Lying Down
What makes your pain better?	Relaxing it down
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dodson
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Cardiovascular Issues Diabetes Type 2 Obesity Osteoarthritis 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.	Morphine. Naproxen. Trelegy
What are your goals from physical therapy?	Approval for MRI
Please list a primary functional activity that you have difficulty performing.	Reaching overhead
How much difficulty do you have in performing this first task?	7/10
Please list a second functional activity that you have difficulty performing.	Reaching behind
How much difficulty do you have in performing this second 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?	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;	Barbara Bither
Signature