Grace Clinic: Patient Care Form – Established Patient
Full Legal Name: ___________________________________________________________________________________
Today’s Date: _______________________________________ Birthday: ______________________________________
Email: ___________________________________________________________________________________________
Primary Care Physician: ________________________________ Other Physicians: ______________________________
The main reason I came to the clinic today is: ____________________________________________________________
How did you hear about the Walk-In Clinic at Grace?   [  ] Advertisement (TV, radio, print)   [  ] Friends   [  ] Family
	My doctor at Grace Clinic: ________________________	My doctor outside of Grace Clinic: ___________________

Please check all that apply below:
[  ] I have changed my medications since my last visit to Grace Clinic.
[  ] I have been hospitalized since my last visit to Grace Clinic.
[  ] I have had surgery performed since my last visit to Grace Clinic.
[  ] I have been diagnosed with new medical problems since my last visit to Grace Clinic.

*Please complete the Review of Symptoms sheet at every visit.*

Review of Symptoms
Please check ALL current problems:
General:
[  ] Fever
[  ] Chills
[  ] Sweats
[  ] Weight loss
[  ] Weight gain
[  ] Other

Eyes:
*Please select right, left or both
[  ] Vision changes (Right and/or Left)
[  ] Eye injury (Right and/or Left)
[  ] Eye irritation (Right and/or Left)
[  ] Other

Ears:
*Please select right, left or both
[  ] Hearing loss (Right and/or Left)
[  ] Earache (Right and/or Left)
[  ] Other

Nose:
[  ] Nasal congestion
[  ] Sinus problems
[  ] Nosebleed
[  ] Other

Mouth and Throat:
[  ] Sores in mouth
[  ] Difficulty swallowing
[  ] Hoarseness
[  ] Sore throat
[  ] Other

Cardiovascular:
[  ] Chest pain
[  ] Shortness of breath
[  ] Swelling of hands or feet
[  ] Other

Respiratory:
[  ] Cough
[  ] Difficulty sleeping
[  ] Wheezing
[  ] Other

Gastrointestinal:
[  ] Nausea
[  ] Vomiting
[  ] Diarrhea
[  ] Abdominal pain
[  ] Bloody stools
[  ] Other

Genitourinary:
[  ] Pain with urination
[  ] Frequent urination
[  ] Difficulty stating or maintaining urination
[  ] Sexual difficulties
[  ] Other

Musculoskeletal:
[  ] Muscle cramps or aches
[  ] Joint pain or swelling
[  ] Back pain
[  ] Other

Skin:
[  ] Rash
[  ] Itching
[  ] Suspicious lesions
[  ] Other

Breasts:
[  ] Lumps or masses
[  ] Nipple discharge
[  ] Tenderness
[  ] Other

Neurological:
[  ] Headaches
[  ] Seizures
[  ] Weakness or numbness
[  ] Other

Psychological:
[  ] Depression
[  ] Anxiety
[  ] Other

Endocrine:
[  ] Cold intolerance
[  ] Heat intolerance
[  ] Excessive thirst or urination
[  ] Other

Hematological:
[  ] Abnormal bruising
[  ] Abnormal bleeding
[  ] Other

Allergy:
[  ] Seasonal allergies
[  ] Other

I have answered the above questions to the best of my ability (please sign below).
Signed: _____________________________________________ Date: ____/____/______