Online Admission Form - Reliant Physical Therapy

Date	07/28/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Twinkie Denise Vivians
Gender	Female
Date of Birth	09/17/1989
Email	Email hidden; Javascript is required.
Address	2966 Attala Road 1022 Kosciusko, Mississippi 39090 Map It
Cell Phone	(601) 507-3220
Which clinic will you receive treatment at?	Kosciusko
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Magnolia Health - MS CAN/MS CHIP
Primary Insurance ID Number	360510166
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Twinkie Denise Vivians
Primary Insurance: Insured Party DOB	09/17/1989
Primary Insurance: Insured Party Gender	Female
Primary Insurance: Insured Address	2966 Attala Road 1022 Kosciusko, Mississippi 39090 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	Alexander Riley
Emergency Contact 1: Phone Number	(662) 633-0282
Emergency Contact 2: Name	Alice Fletcher
Emergency Contact 2: Phone Number	(662) 582-2576
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Pelvic
Patient Maritial Status	Single
Briefly describe your symptoms:	I been having pelvic pain since I had my first child. They thought I had endometriosis in 2025 but I didn’t. I ended up having an enlarged uterus and that let to me having a partial hysterectomy March 3, 2026. But the pelvic pain did not stop but still continued.
How did your symptoms start?	I been having this pain about little more than 5 years
What is your biggest complaint?	Pelvic pain
How often do you experience your symptoms?	Occasionally (26-50% of the time)
Did you have surgery?	Yes
Date of Surgery	03/03/2026
Surgical Procedure:	Partial hysterectomy
Rate your overall health:	Good
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	A Little Bit
Pain
Where is the location of your pain?	Pelvic area
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?	8/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	5/10 - Moderate Pain
Pain Description (Please check all that apply)	Dull/Achy Intermittent Worse in PM
What makes your pain worse?	Sitting Lying Down
Employment
Are you employed?	Yes
Patient Employer	Baptist
Occupation	Receptionist
Patient Employment Status	Full Time
Duty Level of Work:	Very Light
Are you currently working?	Yes - Regular Duty
Patient Employer Address	220 Highway 12 west Kosciusko, Mississippi 39090 Map It
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Jordan Blocker
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Seizures
Have you had any diagnostic imaging studies for this injury?	CT Scan
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.	Baclofin 10mg; hydroxyzine pamoate 25mg
Please list any allergies you may have and your bodies response to this allergy.	Penicillin
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Left femur, left acl, 2 c-section, partial hysterectomy
What are your goals from physical therapy?	To stop this pelvic pain
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;	Twinkie l Vivians
Signature