Difference between revisions of "Karynn Ehlanii Brice/Medical Record"

From 118Wiki
Jump to navigation Jump to search
(Created page with "{{subst:Medical Record}}")
 
(LAST NAME, FIRST NAME MIDDLE NAME)
Line 4: Line 4:
 
|width="600" colspan=2|[[File:Starfleet Medical.png|right|150px|link=Category:Medical Records]]
 
|width="600" colspan=2|[[File:Starfleet Medical.png|right|150px|link=Category:Medical Records]]
 
===LAST NAME, FIRST NAME MIDDLE NAME===
 
===LAST NAME, FIRST NAME MIDDLE NAME===
*'''[[StarFleet Serial Number Register|Patient Reference Number:]]''' EZ - 123 - 456
+
*'''[[StarFleet Serial Number Register|Patient Reference Number:]]''' DJ-385-263
*'''Date of Birth:'''
+
*'''Date of Birth:''' 235704.08
**'''Age:''' {{age|2360|03|31}}
+
**'''Age:''' 34
*'''Sex:'''
+
*'''Sex:''' Female
*'''Species:'''
+
*'''Species:''' Haliian
 
|-
 
|-
 
|style="background:teal; border-radius: 0 0 0 14px; border:0px solid #AFA3BF"|
 
|style="background:teal; border-radius: 0 0 0 14px; border:0px solid #AFA3BF"|
Line 16: Line 16:
 
|style="background:teal; border-radius: 14px 0 0 0; border:0px solid #AFA3BF"|
 
|style="background:teal; border-radius: 14px 0 0 0; border:0px solid #AFA3BF"|
 
|colspan=2|
 
|colspan=2|
*'''Height:''' 178 cm (5'10")
+
*'''Height:''' 5'4"  
*'''Weight:''' 73 kilos (160 lbs)
+
*'''Weight:''' 125 lbs.
*'''Blood Type:'''
+
*'''Blood Type:''' Not Human
*'''[[T/E Rating]]:'''
+
*'''[[T/E Rating]]:''' E3
 
|-
 
|-
 
|style="background:teal;"|
 
|style="background:teal;"|
 
|colspan=2|
 
|colspan=2|
 +
 
===PAST MEDICAL HISTORY===
 
===PAST MEDICAL HISTORY===
 
*'''Chronic Illnesses:'''
 
*'''Chronic Illnesses:'''

Revision as of 15:04, 20 May 2014

Starfleet Medical.png

LAST NAME, FIRST NAME MIDDLE NAME

MEDICAL RECORD
  • Height: 5'4"
  • Weight: 125 lbs.
  • Blood Type: Not Human
  • T/E Rating: E3

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: