Template:Medical Record: Difference between revisions

Revision as of 07:04, 29 April 2014

	LAST NAME, FIRST NAME MIDDLE NAME Patient ID Number: Date of Birth: Age: 41 Sex: Species:
		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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 |colspan=2|[[File:Starfleet Medical.png|right|150px|link=]]
-===IDENTIFYING INFORMATION===
+===LAST NAME, FIRST NAME MIDDLE NAME===
-*'''Name:'''
+*'''Patient ID Number:'''
 *'''Date of Birth:'''
 **'''Age:''' {{age|2360|03|31}}
 *'''Sex:'''
 *'''Species:'''
-*'''Patient ID Number:'''
 |-
 |style="background:teal; border-radius: 0 0 0 14px; border:0px solid #AFA3BF"|