atadiscoverer: (Default)
[personal profile] atadiscoverer
PATIENT MEDICAL HISTORY
Name: Age: 35 years Sex: Male Height: 5'8.4"/174cm Weight: 150lbs/71kg
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[ ] 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
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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.
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Blood Pressure: [X ] Average | [ ] Low | [ ] High
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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
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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
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atadiscoverer: (Default)
Dr. Carson Beckett

March 2015

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