Template:Medical Record: Difference between revisions

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*'''Medications:'''
*'''Medications:'''
*'''Allergies and Reactions:'''
*'''Allergies and Reactions:'''
*'''Reproductive History:'''
*'''Sexual/Reproductive History:'''
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===PAST HOSPITALIZATIONS/SERIOUS ILLNESS===
===PAST HOSPITALIZATIONS/SERIOUS ILLNESS===
*'''SD 237005.05:'''
*'''SD 237005.05:'''

Revision as of 07:01, 29 April 2014

Starfleet Medical.png

IDENTIFYING INFORMATION

  • Name:
  • Date of Birth:
    • Age: 41
  • Sex:
  • Species:
  • Patient ID Number:
MEDICAL RECORD
  • Height:
  • Weight:
  • Blood Type:

PAST MEDICAL HISTORY

  • Chronic Illnesses:
  • Medications:
  • Allergies and Reactions:
  • Sexual/Reproductive History:

PAST HOSPITALIZATIONS/SERIOUS ILLNESS

  • SD 237005.05:
  • SD 237007.05:

PAST SURGICAL HISTORY

  • SD 237005.05:
  • SD 237007.05:

PSYCHIATRIC HISTORY

SUBSTANCE USE HISTORY

  • Alcohol:
  • Recreation Drugs:
  • Other:

FAMILY MEDICAL HISTORY

  • Mother:
  • Father:
  • Siblings:

SOCIAL HISTORY

  • Marital status:
  • Children:
  • Occupation/Assignment:
  • Diet:
  • Exercise:

PHYSICIANS' NOTES

  • Medical Officer:
  • Medical Assessment:

COUNSELORS' NOTES

  • Counselor:
  • Psychological Assessment:
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