Nikolas Malik/Medical Record

	LAST NAME, FIRST NAME MIDDLE NAME Patient Reference Number: EZ - 123 - 456 Date of Birth: Age: 41 Sex: Species:
		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: