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New Patient Registration


I have already completed the full registration paperwork after August 1, 2018.
I have not completed any paperwork after August 1, 2018.
I am not sure whether I've completed the necessary paperwork or not.

Thank you for completing your full registration paperwork. No additional information is needed at this time.

Please complete the following registration form. To ensure your information routes correctly, please select the clinic you're going to visit from the Clinic drop down menu.

Please Note: Fields in red are required.
Female Male
Yes No
Single Married Widowed Divorced Other
English Spanish Other
Employment
Full-time Part-time Retired Self-employed Unemployed Disabled Minor
Person Responsible for Bill
Same as Patient Parent/Guardian* Other*

*If other than patient please fill in the following information*

Full-time Part-time Retired Self-employed Unemployed Disabled

Insurance

Same as Patient Spouse Parent/Guardian Other:

*If other than patient please fill in the following information*

Full-time Part-time Retired Self-employed Unemployed Disabled

*If other than patient or primary insurance subscriber please fill in the following information*

Full-time Part-time Retired Self-employed Unemployed Disabled

I hereby authorize my provider to furnish my insurance company or its representative or permit my insurance company or its representative to review any information requested with respect to any illness or accident, medical history or copies of hospital and medical records. A photostatic copy of this authorization shall be considered as valid as the original. I hereby authorize payment directly to my provider for this illness or injury, of the provider’s benefits otherwise payable to me, but not to exceed my indebtedness to said provider. I agree to pay the provider for all my charges whether or not covered by this assignment. The responsible party hereby agrees that the provider’s office or the party responsible for the billing of these services may check credit with any source to obtain credit information. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This release may include information which may be considered a communicable or venereal disease which may include, but are not limited to diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS). I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above and grant the request of authorizations. I have been notified that I may receive services from the Advanced Practice Provider at this location.

I have been notified that I may receive services from the Advanced Practice Provider at this location.
PLEASE NOTE: The patient portion of the bill is due at the time of service unless prior arrangements have been made.
**
Nov 23 2024

Salina Regional Health Center Authorization to Verbally Release Protected Health Information & Emergency Contact List

Emergency Contact
Yes No

Additional Contact 1
Yes No
Yes No

Additional Contact 2
Yes No

Additional Contact 3
Yes No
I authorize Salina Regional Health Center, and all affiliates, health care providers to provide verbal information concerning my health care to those that I have listed below while I am a patient. Verbal requests for information from other friends, family, caretakers, concerning my health care will not be disclosed without an additional authorization from me. (Exception: Health Information may be disclosed without authorization in an emergency situation or if SRHC determines that the disclosure is in my best interest and the information disclosed is limited to those persons involved in my care).
I may revoke this authorization at any time by notifying my nurse. I have read the above and authorize verbal disclosure of my medical condition. I understand that treatment is not conditioned upon the execution of this authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by those regulations.
**
Nov 23 2024
(Note: Any requests for restriction/communication accommodation should be forwarded to the Privacy Office for approval on the "Request for Disclosure Restriction/Communication Accommodation Form")

Health History

Personal Medical History (check all that apply)

HEENT (Head, ears, eyes, nose and throat)
Endocrine
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Hematology/Oncology
Infectious Disease
Integumentary
Neurologic
Other Medical History:
Surgical History
Surgery Year Surgery Year
Social History
No Yes drink(s) per week
No Yes
No Yes Former
Family Medical History
Relative Health Issues Age & Cause of Death
Mother
Father
Sibling
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other

Prescription and Non-Prescription Medication List

Medication Name Dosage How often do you take? What is the medication for? Prescribing Provider

Medication Allergies

Yes No

Medication Name Reaction

Child Behavioral Past Family Social History (PFSH)

Patient: Date of Birth:
Name of Person completing form
Presenting Problem (briefly describe issues which led to your decision to seek services):
How severe, on a scale of 1-10 (10 being the most severe), do you rate the presenting problem?
1 2 3 4 5 6 7 8 9 10 (severe)
Symptoms causing concern, distress, or impairment:
Loss of Interest Delusions Visual Hallucinations
Anxiety Depressed Mood Hopelessness
Decreased Concentration Increased Energy Helplessness
Cognitive Concerns Decreased Energy Irritability
Crying Spells Auditory Hallucinations Mood Fluctuations
Suicidal Ideation Negativism Panic Attacks
Increased Sleep Decreased Sleep Sex Drive
How long has this problem been causing your child distress?

Psychiatric/Psychological History

Is your child currently being seen by a counselor? No Yes
If yes, name of counselor: How long?
Is your child currently being seen by a psychiatrist? No Yes
If yes, name of psychiatrist: How long?
Has your child ever been diagnosed with a mental health, emotional, or psychological condition?
No Yes
If yes, do you know the diagnosis you were given?
When was this diagnosis given?
Dates of Service Place/Provider Reason for Treatment Were the services helpful?

Safety Concerns

Are you concerned your child is presently suicidal? Yes No
If yes, please explain:
Does your child have a history of harming themselves? Yes No
If yes, please explain:
Has your child ever attempted suicide? Yes No
If yes, when and how?
Is there a history of suicide in the immediate and/or extended family? Yes No
Has your child been having any thoughts of hurting someone else? Yes No
If yes, please explain.
Primary Care Physician Phone
Please list medications (psychotropic, over-the-counter, or herbal remedies) you have taken for any mental illness diagnosis in the past six months.
Medication Dosage Frequency Prescriber Reason for medication
Were any of these medications helpful? Yes No
Please explain.
Are the medications being taken as prescribed? Yes No

Family Mental Health History

Please identify if any members of your child's family have had a history of any of the following mental health/drug abuse/legal concerns.
Family
Member		 Depression Anxiety Bipolar Disorder Schizophrenia ADHD Trauma History Abusive Behavior Alcohol Abuse Drug Abuse Incarceration
Mother
Father
Sister
Brother
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather

Relationships

Mother's name Mother's age
Living with child? Yes No Currently employed? Yes No
Place of employment Occupation
Father's name Father's age
Living with child? Yes No Currently employed? Yes No
Place of employment Occupation
Marital Status Single Married Divorced Widowed Domestic Partnership
How does your child identify themselves? Heterosexual Homosexual Bisexual Questioning
Are they currently employed? Yes No Occupation
Has your child had any recent losses in their life? Yes No
Please explain:
Please list the names, ages, relationships and other relevant information for your child's immediate family members, whether living in- or outside the home. Please include all members currently residing in their household.
Name Gender Age Relationship Living in your home (yes/no)
What else do you feel/believe would be helpful, or important, for us to know or understand about your child's relationships with their family or about your family members?
Has your child ever been in foster care? Yes No From age to age
Family placement or non-familial placement?
Has your child ever been a victim of any abuse?
Type of Abuse By Whom? At What Age? Was it Reported? (yes/no)
Sexual
Physical
Emotional
Verbal
Abandoned/neglected
Bullying
Do you feel like they are in danger now? Yes No
If yes, from whom?

Alcohol/Substance Abuse (if applicable)

At what age did your child first drink?
If applicable, at what age did your child first use substances?
Current/past history of alcohol/substance abuse? Yes No
Has your child ever experienced any problems related to their alcohol/substance use?
Legal Social/Peer Work Family Friends Financial
If yes, please describe:
Has your child ever had alcohol/substance abuse treatment? Yes No
How many years of sobriety do they have?
Does your child use any tobacco products? Yes No

Legal Involvement

Please check below your child's legal status.
No Involvement Probation Parole Charges Pending Prior Incarceration Lawsuit or other court proceeding
Charges
Probation/Parole Officer Contact number

Pregnancy and Birth History

Were there any complications during pregnancy? Yes No
If yes, please explain:
Was it a full term birth or premature birth?
Were drugs or alcohol used during pregnancy? Yes No
Child's weight at birth: lbs oz
Child's health at birth:
Length of hospital stay Postpartum depression? Yes No
Was your child adopted? Yes No If yes, at what age?

Developmental History

As accurately as you can remember, how old was your child when they:
Rolled over Crawled Walked Talked (two words) Toilet Trained
Do/Did you have any concerns about your child's development in any of the areas below?
Speech/Language Motor Skills Cognitive/Intellectual Sensory Behavioral Emotional Social
If so, please describe.
Were there any significant disturbances/changes during their childhood? Yes No
If yes, please explain.

Current Functioning

Do you have any concerns about your child in the following areas?
Eating Hygiene/grooming Sleeping Activities/Play Social Relationships
If so, please describe.

Education

Is your child currently enrolled in school? Yes No
What grade is your child in (if summer, what grade is your child going into)?
How is your child's attendance? Attending regularly Home-schooled Some truancy Suspended Expelled Dropped out GED program
What are your child's achievements/grades in school? A B C D F
Does your child participate in any sport activities? Yes No
How would you describe your child's attitude toward school?
Disciplinary or behavioral issues at school? Yes No
If yes, please describe.
Please check if your child has any of the following:
Special Education Accommodations or a 504?
Describe:
An Individualized Education Plan (IEP)?
Describe:
Diagnosed Learning Disability?
Describe:
Receiving special services at school?
Describe:

Parent/Child Relationship

Describe parenting your child (e.g. challenging, easy)
What do you find most challenging in parenting your child?
What kind of discipline works best with your child?

Strengths/Resources/Supports

What does your child identify as their strengths?
Do you feel they have any limitations?
What are they?
What resources can you identify to help with the current problem?
Is your child involved in a spiritual organization?
Do you see this as a resource for them?
Who can they count on for support?
What do you feel is their biggest need right now?
What do you hope to gain from services with us?
What are three goals you would like to work on?
Goal 1
Goal 2
Goal 3
Is there anything else you would like us to be aware of?

Adult Behavioral Past Family Social History (PFSH)

Patient: Date of Birth:
Name of Person completing form:
Presenting Problem (briefly describe issues which led to your decision to seek services):
How severe, on a scale of 1-10 (10 being the most severe), do you rate the presenting problem?
1 2 3 4 5 6 7 8 9 10 (severe)
Symptoms causing concern, distress, or impairment:
Loss of Interest Delusions Visual Hallucinations
Anxiety Depressed Mood Hopelessness
Decreased Concentration Increased Energy Helplessness
Cognitive Concerns Decreased Energy Irritability
Crying Spells Auditory Hallucinations Mood Fluctuations
Suicidal Ideation Negativism Panic Attacks
Increased Sleep Decreased Sleep Sex Drive
How long has this problem been causing you distress?

Psychiatric/Psychological History

Are you currently being seen by a counselor? No Yes
If yes, name of counselor: How long?
Are you currently being seen by a psychiatrist? No Yes
If yes, name of psychiatrist: How long?
Have you ever been diagnosed with a mental health, emotional, or psychological condition?
No Yes
If yes, do you know the diagnosis you were given?
When was this diagnosis given?
Dates of Service Place/Provider Reason for Treatment Were the services helpful?

Safety Concerns

Are you presently suicidal? Yes No
If yes, please explain:
Have you ever attempted suicide? Yes No
If yes, when and how?
Is there a history of suicide in your immediate and/or extended family? Yes No
Are you presently having any thoughts of hurting someone else? Yes No
If yes, please explain.
Primary Care Physician Phone
Please list medications (psychotropic, over-the-counter, or herbal remedies) you have taken for any mental illness diagnosis in the past six months.
Medication Dosage Frequency Prescriber Reason for medication
Were any of these medications helpful? Yes No
Please explain.
Are the medications being taken as prescribed? Yes No

Family Mental Health History

Please identify if any members of your family have had a history of any of the following mental health/drug abuse/legal concerns.
Family
Member		 Depression Anxiety Bipolar Disorder Schizophrenia ADHD Trauma History Abusive Behavior Alcohol Abuse Drug Abuse Incarceration
Mother
Father
Sister
Brother
Biological
Child
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather

Relationships

How do you identify yourself? Heterosexual Homosexual Bisexual Questioning
If applicable, list divorces and separations
Spouse/significant other's name Age
Are they currently employed? Yes No Occupation
Have you had any recent losses in your life? Yes No
Please explain:
Please list the names, ages, relationships and other relevant information for your immediate family members, whether living in- or outside the home. Please include all members currently residing in your household.
Name Gender Age Relationship Living in your home (yes/no)
What else do you feel/believe would be helpful, or important, for us to know or understand about your relationships with your family or about your family members?
Have you ever been in foster care? Yes No From age to age
Family placement or non-familial placement?
Are your parents married? Yes No
If no, what age were you when they divorced?
Have you ever been a victim of any abuse?
Type of Abuse By Whom? At What Age? Was it Reported? (yes/no)
Sexual
Physical
Emotional
Verbal
Abandoned/neglected
Do you feel like you are in danger now? Yes No
If yes, from whom?

Alcohol/Substance Abuse (if applicable)

At what age did you first drink?
If applicable, at what age did you first use substances?
Current/past history of alcohol/substance abuse? Yes No
If yes, please complete the information below. If no, please continue to the next section.
Do you ever drink/use more than you intend to? Yes No
If yes, how often?
Have you ever had to increase the amount of alcohol/drug you use to get the same effect? Yes No
Do you have a history of ever overdosing on alcohol/drugs? Yes No
If yes, when?
Have you ever experienced a blackout? Yes No
If yes, how often?
Do you have a history of seizures while under the influence? Yes No
Who do you usually drink with?
Have you ever experienced any problems related to their alcohol/substance use?
Legal Social/Peer Work Family Friends Financial
If yes, please describe:
Have you ever had alcohol/substance abuse treatment? Yes No
How many years of sobriety do you have?

Legal Involvement

Please check below your legal status.
No Involvement Probation Parole Charges Pending Prior Incarceration Lawsuit or other court proceeding
Charges
Probation/Parole Officer Contact number

Strengths/Resources/Supports

What do you identify as your strengths?
Do you feel you have any limitations?
What are they?
What resources can you identify to help with the current problem?
Are you involved in a spiritual organization?
Do you see this as a resource for you?
Who can you count on for support?
What do you feel is your biggest need right now?
What do you hope to gain from services with us?
What are three goals you would like to work on?
Goal 1
Goal 2
Goal 3
Is there anything else you would like us to be aware of?

Thank you for choosing Salina Pediatric Care as the source of your child's healthcare. To help us get to know your child, please take a few minutes to answer the following questions.

No Yes
No Yes
No Yes
No Yes
No Yes

Family History

Is there a family history of any of the following? (please list child's parents, grandparents, siblings, aunts, uncles and cousins):
No Yes Relation
Deafness/Hearing Problems No Yes
Nasal Allergies No Yes
Asthma or Wheezing No Yes
Tuberculosis No Yes
Heart Disease - Heart Attacks, Strokes or Hardening of Arteries prior to age 50 No Yes
High Blood Pressure prior to age 50 No Yes
High Cholesterol No Yes
Anemia No Yes
Bleeding Disorders No Yes
Liver Disease No Yes
Kidney Disease No Yes
Diabetes prior to age 50 No Yes
Bed-Wetting after age 10 No Yes
Epilepsy or Convulsions No Yes
Alcohol Abuse No Yes
Drug Abuse No Yes
Mental Illness No Yes
Mental Retardation No Yes
Immune Problems, HIV or AIDS No Yes
Thyroid Disease (High or Low) No Yes
Sickle Cell Disease No Yes
Sudden Infant Death Syndrome (crib death) No Yes
Cystic Fibrosis No Yes
Autism No Yes
Birth Defects or Abnormalities No Yes

Additional Information


RIGHT LEFT - RIGHT LEFT
Pain - Heaviness
Aching - Fatigue
Cramping - Restless Leg
Burning - Phlebitis
Itching - Non Healing Sore
Swelling - Bleeding from a vein

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No Does not apply
Yes No
Yes No
Yes No
Appointments:
  • Ultrasounds are performed in the hospital, 400 S. Santa Fe (go to Registration first)
  • Vein Clinic appointments are in the Medical Plaza, 501 S. Santa Fe, 2nd floor (arrive 15 minutes early)
Please review and update the medication list. If you have never been seen at any of our other clinics or the hospital, we won't have a list in our system. Please bring your medication bottles of all medications that you take, both prescription and over the counter.

Each time you come to the clinic, please bring loose fitting shorts and your compression hose if you have them.
Phone: 785-452-7562 Fax: 785-452-7105 After hours phone: 785-452-4017
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired?

This refers to your usual ways of life in recent times.

Even if you haven't done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:
  • 0 = Would never doze
  • 1 = Slight chance of dozing
  • 2 = Moderate chance of dozing
  • 3 = High chance of dozing
Situation Chance of Dozing
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting, inactive in a public place (e.g. a theatre or meeting) 0 1 2 3
As a passenger in a car for an hour without a break 0 1 2 3
Lying down to rest in the afternoon when circumstances permit 0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after a lunch without alcohol 0 1 2 3
In a car, while stopped for a few minutes in traffic 0 1 2 3
Total:
0
Score:
  • 0 - 10 = Normal
  • 10 - 12 = Borderline
  • 12 - 24 = Abnormal
Pneumonia Vaccination
(mild) 1 2 3 4 5 6 7 8 9 10 (severe)
No Yes

Constant Variable
Dull then sharp Very sharp then leaves Always There

Yes No
No Yes
DVT
Dialysis
Malignant Hyperthermia
Joint injuries, specifically:

Thank you for choosing Salina Regional Orthopedic & Sports Medicine Clinic. To help us serve you better, please take a few minutes to answer the following questions:

Laterality
Right Left
(mild) 1 2 3 4 5 6 7 8 9 10 (severe)
(mild) 1 2 3 4 5 6 7 8 9 10 (severe)
Yes No
Popping Numbness
Clicking Tingling
Grinding Edema
Yes No

Medication Physical Therapy
Injection Occupational Therapy
Bracing Other:

Current Complaints (please check all that apply)

Other:
Please review your entries for accuracy before submitting the form.