Online Admission Form - Reliant Physical Therapy

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Date	06/18/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Melissa Mary Crawford
Gender	Female
Date of Birth	02/05/1968
Email	Email hidden; Javascript is required.
Address	4646 twilight cove Pearl, Mississippi 39208 Map It
Cell Phone	(601) 937-0139
Which clinic will you receive treatment at?	Pearl
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Aetna
Primary Insurance ID Number	102081260100
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Melissa Mary Crawford
Primary Insurance: Insured Party DOB	02/05/1968
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	4646 twilight cove Pearl, Mississippi 39208 Map It
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Scott Crawford
Emergency Contact 1: Phone Number	(601) 937-0660
Emergency Contact 2: Name	Emily Yates
Emergency Contact 2: Phone Number	(443) 766-0257
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Hip/lower back
What side of the body will we be treating?	Left
Date of Injury or when your pain began.	05/01/2026
Is this injury due to:	Other unknown
Patient Maritial Status	Married
Briefly describe your symptoms:	Pain started in my lower abdomen and went to my left pelvic bone, left leg and left hip. Because of sitting more and walking with a limp, my lower back (which has arthritis) has also started hurting. But the primary pain is the pelvic bone and left leg.
How did your symptoms start?	I think I noticed the pain in my left inner thigh first but write it off as having aggravated a past muscle tear in that location. But then I had some pulsating pain in my lower abdomen which I thought might be a cyst on my ovary. But within a day or two, I had pain in my left pelvic bone which had been constant since then and making my leg pain spread and worsen.
What is your biggest complaint?	Pelvic/hip and left leg 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 Shower Stall
Living Situation	Lives with Family
Do you now or have you ever smoked?	No
Do you have a history of falling?	Yes
How many falls have you had in the past year?	Maybe 1
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:	Chores
Please check or describe any limitations you have experienced in your Mobility:	Housekeeping Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Squatting
Pain
Where is the location of your pain?	Left hip/pelvic bone/leg
What is the WORST your pain gets on a 0 - 10 Scale?	9/10
What is the BEST your pain gets on a 0 - 10 Scale?	4/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Sharp Dull/Achy Constant Worse in PM Worse at night while sleeping
What makes your pain worse?	Sitting Standing Walking Going Up Stairs Going Down Stairs Standing Lying Down
What makes your pain better?	I have been taking nsaids and Tylenol and using diclonfec gel and sometimes ice. Also elevating
Employment
Are you employed?	No
Are you disabled or currently on disability?	Yes
When did you become disabled or on disability?	2023
What is the reason you are disabled?	TBI from a fall
What doctor referred you to therapy?	Dr Austin Barrett
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Obesity Osteoarthritis Traumatic Brain Injury Seizures
Have you had any diagnostic imaging studies for this injury?	Other both x-ray and ct
Have you had any recent or unexplained weight loss?	Yes
Are you taking any of the following?	Prescription Medications Over the Counter Medications Herbal Supplements Vitamin/Mineral/Dietary Supplements
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Levothyroxin, albuterol sulfate rescue inhaler , diclonfec sodium DRT, methocarbam, sumatriptan (as needed for migraine), condensation ODT (as needed for nausea)
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Allegra, diclofinec topical gel, docusate sodium, Tylenol, sometimes Benadryl or chlorpheniramine maleate
Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.	menopause support complex, tumeric,
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	While food women’s vitamin, cholesteOff plus, coQ10, vitamin d & E, calcium, magnesium glycinate, pro and pre biotic,
Please list any allergies you may have and your bodies response to this allergy.	Tramadol and codeine (severe itching) and 2 unknowns: I ate something that shut my lungs down & had severe burning to something in a prescription allergy eye drops
What are your goals from physical therapy?	To reduce pain and walk with regular gait again
Please list a primary functional activity that you have difficulty performing.	Walking without pain
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
Please list a second functional activity that you have difficulty performing.	Standing
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.	Squatting
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?	Other Adam is my nephew and I have had PT at reliant in the past.
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;	Melissa Crawford
Signature