Trans 9 Medical info
Jan. 15th, 2012 10:31 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
PATIENT MEDICAL HISTORY | ||||
Name: | Age: 35 years | Sex: Male | Height: 5'8.4"/174cm | Weight: 150lbs/71kg |
. | ||||
[ ] Magical by nature/practices magic. | [ ] Can't have magic used on. | [ ] Contagious (see notes). | ||
Homo Sapiens [Human] | ||||
Average Lifespan: 80 | Rate of Maturity: Between ages 18 and 22 | Average age of Puberty: 13 | ||
. | ||||
Normal Diet: Omnivorous Common Ailments: Specific Notes: (healing factors, special needs, etc) None |
||||
GENERAL HEALTH | ||||
All of the following sense-related questions are to be answered in comparison to an average Homo sapiens. Ask your medical provider for assistance in answering this section. |
||||
. | ||||
Blood Pressure: [X ] Average | [ ] Low | [ ] High | ||||
. | ||||
Vision: [X ] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced | ||||
If Enhanced, further explain: |
||||
. | ||||
Hearing: [ ] Deaf | [ ] Low | [X ] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive | ||||
If necessary, further explain: |
||||
. | ||||
Smell: [ ] Cannot Smell | [ ] Low | [X ] Average | [ ] High | [ ] Extremely Sensitive | ||||
If Extremely Sensitive, further explain: |
||||
. | ||||
Known Allergies: Cats Are there any potential complications with healing processes we should be aware of when treating you?: None Do you have a healing factor different from the average for your species? If so, explain how here: None Have you recently been screened for species, sex, and age specific cancer risks?: Yes Special notes on care: (Such as contagious diseases/conditions, special means of handling, special care taken in handling) None Record of Past Injuries: N/A Ship Health Records: N/A |
||||
SEXUAL HEALTH | ||||
Have you ever been sexually active?: | Yes [X ] No [ ] | |||
Are you currently sexually active?: | Yes [X ] No [ ] | |||
Have you recently been screened for STIs?: | Yes [ ] No [X ] | |||
Species specific sexually related health notes and/or issues: General human STIs |
||||
. | ||||
Reproductive Health (skip if N/A) | ||||
. | ||||
Date of Last Menses/Estrus/Equiv (skip if n/a): Number of pregnancies: Number of pregnancies carried to term: Age of first birth/hatching/etc. (if applicable): Total number of births/hatching/etc.: |
||||
DRUGS AND MEDICINE | ||||
Are you or should you be on any prescribed medication? If so, list below: No Have you taken any recreational or non-prescribed drugs or substances in the past? If so, please list them and their frequency of use below: Alcohol - Infrequent Do you currently take any recreational or non-prescribed drugs or substances? If so, please list them and their frequency of use below: Alcohol - Infrequent |
||||
. |