Online Admission Form - Reliant Physical Therapy

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Date	06/14/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Zander Rust
Gender	Male
Date of Birth	05/31/2011
Email	Email hidden; Javascript is required.
Address	405 Millrun Rd Brandon, Mississippi 39047 Map It
Home Phone	(812) 239-0145
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	Justin Rust
Guarantor Gender	Male
Guarantor Date of Birth	06/24/1981
Guarantor Phone	(812) 236-2706
Guarantor Address	405 Millrun Rd Brandon, Mississippi 39047 Map It
Insurance Information
Primary Insurance	Aetna
Primary Insurance ID Number	W293025116
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	Justin Rust
Primary Insurance: Insured Party DOB	06/24/1981
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(812) 236-2706
Primary Insurance: Insured Address	405 Millrun Rd 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	Julie Rust
Emergency Contact 1: Phone Number	(812) 239-0145
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	left lower back and right hamstring
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	06/01/2026
Is this injury due to:	Sports Related
Patient Maritial Status	Married
Briefly describe your symptoms:	Lower back pain (lumbar sprain); and tight hamstrings
How did your symptoms start?	Initial back pain happened two weeks ago but got aggravated more one week ago; still quite sore
What is your biggest complaint?	Pain keeps him up at night; unable to compete in basketball
How often do you experience your symptoms?	Frequently (51-75% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	Two Story Home
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	Quite a Bit
Please check or describe any limitations you have experienced in your Self Care:	Sleeping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Squatting
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Recreation Kicking/Pushing with Legs Pulling/Pushing Objects
Pain
Where is the location of your pain?	lower back (mostly left) but both hamstrings are tight as well
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)	Sharp Dull/Achy Intermittent Worse at night while sleeping
What makes your pain worse?	Sitting Standing Walking Bending Lying Down
What makes your pain better?	Not twisting back in any way
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Nathan Wagner
Medical History
Do you have any of the following medical conditions? (Check all that apply)	I have no significant Medical History
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
What are your goals from physical therapy?	To get rid of pain; To get back to basketball; To learn stretches and movements that will prevent injuries in the first place (hamstring and back)
Please list a primary functional activity that you have difficulty performing.	Twisting, bending, touching toes,
How much difficulty do you have in performing this first task?	6/10
Please list a second functional activity that you have difficulty performing.	jumping, running
How much difficulty do you have in performing this second task?	3/10
Please list a third functional activity that you have difficulty performing.	changing directions, pivoting
How much difficulty do you have in performing this third task?	2/10
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;	Julie Rust
Signature