Karynn Ehlanii Brice/Medical Record: Difference between revisions

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Revision as of 14:53, 20 May 2014

Starfleet Medical.png

LAST NAME, FIRST NAME MIDDLE NAME

MEDICAL RECORD
  • Height: 178 cm (5'10")
  • Weight: 73 kilos (160 lbs)
  • Blood Type:
  • T/E Rating:

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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