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Medical Form [Trans9]
Oct. 10th, 2011 04:11 pm| PATIENT MEDICAL HISTORY | ||||
| Name: Maxine Hunkel/Cyclone | Age: 19 years | Sex: Female | Height: 170cm/5'7" | Weight: 59kg/130lbs |
| [ ] Magical by nature/practices magic. | [ ] Can't have magic used on. | [X] Contagious (see notes). | ||
| HUMAN (homo sapiens) | ||||
| Average Lifespan: approx. 78 years | Rate of Maturity: approx. 18 years | Average age of Puberty: approx. 13 years | ||
Normal Diet: [Note on human diet attached] Common Ailments: [Note on common human ailments attached] Specific Notes: N/A |
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| 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 | ||||
| Vision: [X] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced | ||||
| If Enhanced, further explain: |
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| Hearing: [ ] Deaf | [ ] Low | [X] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive | ||||
| If necessary, further explain: Actual hearing is average, but patient can carry and move sound waves (as she explained in detail). |
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| Smell: [ ] Cannot Smell | [ ] Low | [X] Average | [ ] High | [ ] Extremely Sensitive | ||||
| If Extremely Sensitive, further explain: |
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| Known Allergies: N/A Are there any potential complications with healing processes we should be aware of when treating you?: See 'special notes on care'. Do you have a healing factor different from the average for your species? If so, explain how here: See 'special notes on care'. Have you recently been screened for species, sex, and age specific cancer risks?: No. Special notes on care: Foreign nanites in her body. In event of extreme physical stress/danger, they will react to preserve her and do repair. However, they can also spread to others in this event, where they will attempt to re-write the systems of compatible hosts (human women of roughly the same make up as the patient). Record of Past Injuries: [Complete history attached] Ship Health Records: N/A |
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| SEXUAL HEALTH | ||||
| Have you ever been sexually active?: No. Are you currently Sexually Active: No. Have you recently been screened for STIs?: No. Species specific sexually related health notes and/or issues: N/A |
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| Reproductive Health (skip if N/A) | ||||
| Date of Last Menses/Estrus/Equiv (skip if n/a): On ship. Number of pregnancies: N/A Number of pregnancies carried to term: N/A Age of first birth/hatching/etc. (if applicable): N/A Total number of births/hatching/etc.: N/A |
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| DRUGS AND MEDICATION | ||||
| Are you or should you be on any prescribed medication? If so, list below: N/A Have you taken any recreational or non-prescribed drugs or substances in the past? Is so, please list them and their frequency of use below: N/A Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below: N/A |
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