Online Admission Form - Reliant Physical Therapy

Date	08/23/2026
Patient Information
Formal Name (as on Insurance Card or Driver License)	Brody Aaron Cliburn
Nickname/Name you liked to be called?	Brody
Gender	Male
Date of Birth	07/21/2011
Email	Email hidden; Javascript is required.
Address	204 Faith Way Brandon, Mississippi 39042 Map It
Home Phone	(601) 408-6186
Cell Phone	(601) 408-6186
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Child
Guarantor Name	William Matthew Cliburn
Guarantor Gender	Male
Guarantor Date of Birth	05/07/1985
Guarantor Phone	(601) 850-9442
Guarantor Address	204 Faith Way Brandon, Mississippi 39042 Map It
Insurance Information
Primary Insurance	Blue Cross Blue Shield
Primary Insurance ID Number	YAX 868219554M
Primary Insurance: Patient's Relationship to Insured Party	Child
Primary Insurance: Insured Party Name	William Matthew Cliburn
Primary Insurance: Insured Party DOB	05/07/1985
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Phone	(601) 850-9442
Primary Insurance: Insured Address	204 Faith Way Brandon, Mississippi 39042 Map It
Do you have a secondary Insurance.	No
Is this a worker's compensation or other accident claim?	Yes
Emergency Contacts
Emergency Contact 1: Name	Erin Cliburn
Emergency Contact 1: Phone Number	(601) 408-6186
Emergency Contact 2: Name	Gary Mayo
Emergency Contact 2: Phone Number	(601) 818-2738
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	lower back
What side of the body will we be treating?	Back
Date of Injury or when your pain began.	08/14/2026
Patient Maritial Status	Single
Briefly describe your symptoms:	Football injury led to extreme back pain. An xray at MS Sports Med. revealed a PARS defect in the L5 area.
How did your symptoms start?	Football injury
What is your biggest complaint?	Turning and rotating hurts the most
How often do you experience your symptoms?	Intermittently (0-25% of the time)
Did you have surgery?	No
Rate your overall health:	Excellent
Home Layout	One 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	Moderately Quite a Bit
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 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-both sides but more on the right side
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?	2/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	2/10
Pain Description (Please check all that apply)	Sharp Intermittent
What makes your pain worse?	Standing Walking Standing Bending
What makes your pain better?	Laying flat
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Kristen Weaver, UMMC Peds Neurosurgery
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?	all of the above
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Hydrocodone
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	IBuprofen
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Creatine
Please list any allergies you may have and your bodies response to this allergy.	none
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	none
What are your goals from physical therapy?	no pain-be ready for baseball season
Please list a primary functional activity that you have difficulty performing.	lifting
How much difficulty do you have in performing this first task?	0/10 - Unable to Perform
Please list a second functional activity that you have difficulty performing.	standing for long periods of time
How much difficulty do you have in performing this second 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?	Ricky Clark
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;	Erin Cliburn
Signature