Online Admission Form - Reliant Physical Therapy

Date	07/20/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Michelle Ann Worman
Gender	Female
Date of Birth	03/23/1979
Email	Email hidden; Javascript is required.
Address	801 Windlass Cv Brandon, Mississippi 39047 Map It
Cell Phone	(205) 301-1107
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Cigna
Primary Insurance ID Number	11081553900
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Michelle Ann Worman
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	801 Windlass Cv 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	Kathy Worman
Emergency Contact 1: Phone Number	(601) 927-5375
Emergency Contact 2: Name	Dave Worman
Emergency Contact 2: Phone Number	(601) 927-5382
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Back
What side of the body will we be treating?	Both
Patient Maritial Status	Single
Briefly describe your symptoms:	Strain of muscle and tendon of back wall of thorax, thoracic spine.
How did your symptoms start?	Year or so
What is your biggest complaint?	Constant back/neck ache
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Very 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?	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:	Chores
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Sitting Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Hand and Arm Use Work/Vocation/Occupation
Pain
Where is the location of your pain?	Upper back/shoulders/neck
What is the WORST your pain gets on a 0 - 10 Scale?	8/10
What is the BEST your pain gets on a 0 - 10 Scale?	2/10
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 Constant Worse in AM Worse in PM
What makes your pain worse?	Sitting Bending
What makes your pain better?	Stretching
Employment
Are you employed?	Yes
Patient Employer	Intradiem, Inc
Occupation	Contracts Administrator
Patient Employment Status	Full Time
Duty Level of Work:	Medium
Are you currently working?	Yes - Regular Duty
Patient Employer Address	2500 Dallas hwy Suite 202 Marietta, Georgia 30064 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Megan Tyson, NP
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Cardiovascular Issues Other
Have you had any diagnostic imaging studies for this injury?	MRI
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	- [ ] Zoloft 150 mg/daily - [ ] Wellbutrin 150 mg/daily - [ ] Clonazepam .5mg/daily - [ ] Estradiol .75 mg/daily - [ ] Pantoprazole 40 mg/daily - [ ] Trulance 3mg/daily - [ ] Rosuvastatin 10 mg/daily
Please list any allergies you may have and your bodies response to this allergy.	Codeine, olive oil
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Full hysterectomy, Gallbladder removal
What are your goals from physical therapy?	Learn how to better my posture, exercises to help pain
Please list a primary functional activity that you have difficulty performing.	Working at desk
How much difficulty do you have in performing this first task?	5/10 - Moderate Difficulty
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;	Michelle Worman
Signature