Online Admission Form - Reliant Physical Therapy

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Date	06/24/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Barbara Halford Bienvenu
Gender	Female
Date of Birth	03/29/1950
Email	Email hidden; Javascript is required.
Address	202 Holly Trail Brandon, Mississippi 39047 Map It
Home Phone	(601) 992-9850
Cell Phone	(601) 497-8247
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Medicare
Primary Insurance ID Number	SRA-RE3-XD51
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Barbara H Bienvenu
Primary Insurance: Insured Party DOB	03/29/1950
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	202 Holly Trail Brandon, Mississippi 39047 Map It
Do you have a secondary Insurance.	Yes
Secondary Insurance	Omaha Ins co
Secondary Insurance ID Number	510459-92
Secondary Insurance: Patient's Relationship to Insured Party	Self
Secondary Insurance: Insured Phone	(800) 775-6000
Secondary Insurance: Insured Party DOB	03/29/1950
Secondary Insurance: Insured Party Gender	Female
Secondary Insurance: Insured Address	202 Holly Trail Brandon, Mississippi 39047 Map It
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	IB Bienvenu Jr
Emergency Contact 1: Phone Number	(601) 992-9850
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	knee
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	06/01/2026
Is this injury due to:	Other
Patient Maritial Status	Married
Briefly describe your symptoms:	I had 2 repairs of meniscus. I had a partial knee replacement. Three years later I had to have the partial removed and had a total knee replacement. That was 13 years ago , now my knee is unstable.
How did your symptoms start?	Knee started feeling unstable. It has always hurt especially at night.
What is your biggest complaint?	Knee is not stable.
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	Yes
Date of Surgery	06/12/2013
Surgical Procedure:	replacement of partial with total
Rate your overall health:	Fair
Living Situation	Lives with Family
Do you have a history of falling?	Yes
How many falls have you had in the past year?	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:	Sleeping Chores
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Prolonged Standing Kneeling Squatting
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Fine Hand Use
Pain
Where is the location of your pain?	knee
What is the WORST your pain gets on a 0 - 10 Scale?	6/10
What is the BEST your pain gets on a 0 - 10 Scale?	3/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	0/10 - No Pain
Pain Description (Please check all that apply)	Dull/Achy 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?	biofreeze/ wrapping
Employment
Are you employed?	Yes
Patient Employer	Castlewoods place
Occupation	Concierge
Patient Employment Status	Part Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	140castlewoods Blvd Brandon, Mississippi 39047 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Dr Pickering
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Cardiovascular Issues Diabetes Type 2 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 Over the Counter Medications Herbal Supplements Vitamin/Mineral/Dietary Supplements
Please list any allergies you may have and your bodies response to this allergy.	Bactrim -Bruising
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Heart valve replacement May 2026
What are your goals from physical therapy?	To
Please list a primary functional activity that you have difficulty performing.	kneeling
How much difficulty do you have in performing this first task?	1/10
Please list a second functional activity that you have difficulty performing.	getting on my knees
How much difficulty do you have in performing this second 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?	Other
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 Bienvenu
Signature