Online Intake Form – Reliant Physical Therapy

Online Admission Form

"*" indicates required fields

Date

Patient Information

Formal Name (as on Insurance Card or Driver License)*

First Middle Last

Nickname/Name you liked to be called?

Gender*

Male

Female

Date of Birth*

Address*

Street Address City State ZIP Code

Home Phone

Cell Phone

Work Phone

Work Phone Extension (if applicable)

Would you like an email or text message reminder about your appointments?

Yes

What type of reminder(s) would you like?

Text Message (2-3 hrs prior to appointment)

Text Messages:

Which clinic will you receive treatment at?*

Pearl

Kosciusko

Flowood

You may opt out at any time.

Guarantor Information

Patient Relationship to Guarantor.

Guarantor Name

First Middle Last

Guarantor Gender

Male

Female

Guarantor Date of Birth

Guarantor Phone

Guarantor Address

Same as patient

Street Address City State ZIP Code

Insurance Information

Primary Insurance*

Primary Insurance ID Number

Primary Insurance: Patient's Relationship to Insured Party

Primary Insurance: Insured Party Name

First Middle Last

Primary Insurance: Insured Party DOB

Primary Insurance: Insured Party Gender

Male

Female

Primary Insurance: Insured Phone

Primary Insurance: Insured Address

Same as patient

Street Address City State ZIP Code

Do you have a secondary Insurance.

Yes

Secondary Insurance

Secondary Insurance ID Number

Secondary Insurance: Patient's Relationship to Insured Party

Secondary Insurance: Insured Party Name

First Middle Last

Secondary Insurance: Insured Phone

Secondary Insurance: Insured Party DOB

Secondary Insurance: Insured Party Gender

Male

Female

Secondary Insurance: Insured Address

Same as patient

Street Address City State ZIP Code

Is this a worker's compensation or other accident claim?

Yes

Claim Number

Case Worker/Adjustor's Name:

First Last

Case Worker/Adjustor's Phone Number

Case Worker/Adjustor's Phone Extension (if applicable)

Emergency Contacts

Emergency Contact 1: Name

First Last

Emergency Contact 1: Phone Number

Emergency Contact 2: Name

First Last

Emergency Contact 2: Phone Number

Basic Information

What part of your body will we be treating today? (hip, knee, back...)

What side of the body will we be treating?

Date of Injury or when your pain began.

Is this injury due to:

Fall

Work Related

Sports Related

Motor Vehicle Accident

Other

What state did the MVA occur in?

Patient Maritial Status

Married

Single

Divorced

Other

Briefly describe your symptoms:

How did your symptoms start?

What is your biggest complaint?

How often do you experience your symptoms?

Constantly (76-100% of the time)

Frequently (51-75% of the time)

Occasionally (26-50% of the time)

Intermittently (0-25% of the time)

Did you have surgery?

Yes

Date of Surgery

Surgical Procedure:

Rate your overall health:

Excellent

Very Good

Good

Fair

Poor

Home Layout

(Hold Ctrl to select multiple items)

Living Situation

Lives with Family

Lives Alone

Lives with Caregiver

Do you now or have you ever smoked?

Yes

How many years did or have you smoked?

On average, about how many packs per day did or do you smoke?

Do you have a history of falling?

Yes

How many falls have you had in the past year?

Have you had prior physical therapy, occupational therapy or chiropractic treatment this year?

Yes

Current Functional Limitations

How much have your symptoms interfered with your usual daily activities

Not at All

A Little Bit

Moderately

Quite a Bit

Extremely

Please check or describe any limitations you have experienced in your Self Care:

(Hold Ctrl to select multiple entries)

Please check or describe any limitations you have experienced in your Mobility:

(Hold Ctrl to select multiple entries)

Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:

(Hold Ctrl to select multiple entries)

Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:

(Hold Ctrl to select multiple entries)

Pain

Where is the location of your pain?

What is the WORST your pain gets on a 0 - 10 Scale?

What is the BEST your pain gets on a 0 - 10 Scale?

What is your pain RIGHT NOW on a 0 - 10 Scale?

Pain Description (Please check all that apply)

(Hold Ctrl to select multiple entries)

What makes your pain worse?

(Hold Ctrl to select multiple entries)

What makes your pain better?

Employment

Are you employed?

Yes

Patient Employer

Occupation

Patient Employment Status

Duty Level of Work:

Are you currently working?

Yes - Regular Duty

Yes, but on Modified or Light Duty

Other

Off work since:

What are your job restrictions?

Patient Employer Address

Street Address Address Line 2 City State ZIP Code

Are you disabled or currently on disability?

Yes

When did you become disabled or on disability?

What is the reason you are disabled?

(this may impact your prognosis, available treatment options...)

What doctor referred you to therapy?

Doctor's Name

Medical History

Would like to complete your medical history online via this form or on paper. If you choose to complete this section on paper, please do so prior to your scheduled evaluation

Complete Medical History Online

I will complete this section on paper prior to my evaluation.

* You may download the paper form and complete this section prior to your evaluation or you may arrive at our facility about 15 min prior to your appointment to complete it in our office.

Do you have any of the following medical conditions? (Check all that apply)

(Hold Ctrl to select multiple entries)

Have you had any diagnostic imaging studies for this injury?

X-Ray

MRI

CT Scan

Other

Have you had any recent or unexplained weight loss?

Yes

Are you taking any of the following?

(Hold Ctrl to select multiple entries)

Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.

Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.

Please list the Herbal Supplements you are taking. You may bring in a list if you prefer to do so.

Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.

Please list the Other medications you are taking. You may bring in a list if you prefer to do so.

Please list any allergies you may have and your bodies response to this allergy.

Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)

What are your goals from physical therapy?

Please list a primary functional activity that you have difficulty performing.

This may be one of the activities you checked earlier that were limited.

How much difficulty do you have in performing this first task?

Please list a second functional activity that you have difficulty performing.

This may be one of the activities you checked earlier that were limited.

How much difficulty do you have in performing this second task?

Please list a third functional activity that you have difficulty performing.

This may be one of the activities you checked earlier that were limited.

How much difficulty do you have in performing this third task?

Are you currently receiving home health services?

Yes

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 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 also acknowledge 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.

WAIVER AND RELEASE

Waiver and Release*

I hereby release, discharge, and acquit this facility, its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive, or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician, or urgent care services.

AUTHORIZATION OF PAYMENT

Authorization of Payment*

I request that payment of services be made by Medicare, third party insurance plan/payor(s), or other source as listed in my admission paperwork on my behalf to Reliant, Inc. I hereby assign all insurance and similar benefits directly to Reliant, Inc. and authorize release of any medical records necessary to process medical claims. I understand that in the event my insurance company or financial responsible party does not pay for services or products, I will be financially responsible.

FINANCIAL RESPONSIBILITY

Financial Responsibility*

In consideration for services to be provided, I consent to pay Reliant, Inc. all amounts that are due or owing for services provided and not paid by Medicare, a third party insurance plan or payor, or other source on my behalf for services so rendered.

NOTICE OF PRIVACY PRACTICES

Notice of Privacy Practices*

I hereby acknowledge that I have been offered or received a copy of Reliant, Inc.’s Notice of Privacy Practices. I understand that I may also view a copy of this document online at https://www.reliantpt.com/privacy-policy/ or request a hard copy at any time in writing to Reliant, Inc., ATTN: Privacy Director; 3825 Highway 80 East; Pearl, MS 39208.

NO SHOW/CANCELLATION FEE:

No Show/Cancellation Fee*

In an effort to enhance each of your therapy visits, we strongly encourage regular attendance. A $30 fee may be charged for all patients who do not show for their appointment.

RELEASE OF INFORMATION:

Release of Information*

According to office policy, medical information will be released to the patient only. Please request and complete a separate Request to Release Medical Information form to specify any third party or individual to whom information may be release to other than yourself. This information would include but not limited to medical information, billing, and other protected health information. (Example: your spouse, son, daughter, sibling, caretaker, friend)

INFORMATION USAGE:

Information Usage*

We respect your privacy and do not tolerate spam. We will never sell, rent, lease or give away your information (name, address, email, etc.) to any third party with the exception of: the payor(s) you have provided for us to send your claims to for processing, court subpoena, in compliance with relevant laws or per your written request.

ELECTRONIC MONTHLY NEWSLETTER:

Electronic Monthly Newsletter*

In an ongoing effort to provide our patients with continued education and the latest healthcare information you may choose to receive monthly emails from our company. You may opt-out at any time, if you prefer to receive our monthly newsletter please sign up above on our online admission form.

Referral Source

How did you find out about us?

Online Search

Phone Book

Doctor

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;*

First Last

(Must be the Patient, Guardian or other legal caretaker)

Signature

Must be Patient, Guardian or other legal caretaker.

Phone

This field is for validation purposes and should be left unchanged.

I have no significant Medical History
Alzheimer's
History of Cancer
Cardiovascular Issues
Huntington's
Cauda Equina
Immunosuppression
Stroke
Lupus
Current Infection
Muscular Dystrophy
Diabetes Type 1
Diabetes Type 2
Obesity
Osteoarthritis
Parkinson's
Fibromyalgia
Fracture
Rheumatoid Arthritis
High Blood Pressure
Traumatic Brain Injury
HIV/AIDS
Bleeding Disorder
Seizures
Fainting Spells
Pacemaker
Currently Pregnant
Other