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{|style="max-width:700px" | |||
|style="background:teal;" width="100"| | |||
|width="600" colspan=2|[[File:Starfleet Medical.png|right|150px|link=Category:Medical Records]] | |||
===LAST NAME, FIRST NAME MIDDLE NAME=== | |||
*'''[[StarFleet Serial Number Register|Patient Reference Number:]]''' EZ - 123 - 456 | |||
*'''Date of Birth:''' | |||
**'''Age:''' {{age|2360|03|31}} | |||
*'''Sex:''' | |||
*'''Species:''' | |||
|- | |||
|style="background:teal; border-radius: 0 0 0 14px; border:0px solid #AFA3BF"| | |||
|style="background:teal" | | |||
!width=180 align=right|<font size="4" color=teal>MEDICAL RECORD</font> | |||
|- | |||
|style="background:teal; border-radius: 14px 0 0 0; border:0px solid #AFA3BF"| | |||
|colspan=2| | |||
*'''Height:''' 178 cm (5'10") | |||
*'''Weight:''' 73 kilos (160 lbs) | |||
*'''Blood Type:''' | |||
*'''[[T/E Rating]]:''' | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===PAST MEDICAL HISTORY=== | |||
*'''Chronic Illnesses:''' | |||
*'''Medications:''' | |||
*'''Allergies and Reactions:''' | |||
*'''Sexual/Reproductive History:''' | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===PAST HOSPITALIZATIONS/SERIOUS ILLNESS=== | |||
*'''SD 237005.05:''' | |||
*'''SD 237007.05:''' | |||
===PAST SURGICAL HISTORY=== | |||
*'''SD 237005.05:''' | |||
*'''SD 237007.05:''' | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===PSYCHIATRIC HISTORY=== | |||
===SUBSTANCE USE HISTORY=== | |||
*'''Alcohol:''' | |||
*'''Recreation Drugs:''' | |||
*'''Other:''' | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===FAMILY MEDICAL HISTORY=== | |||
*'''Mother:''' | |||
*'''Father:''' | |||
*'''Siblings:''' | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===SOCIAL HISTORY=== | |||
*'''Marital status:''' | |||
*'''Children:''' | |||
*'''Occupation/Assignment:''' | |||
*'''Diet:''' | |||
*'''Exercise:''' | |||
|- | |||
|style="background:teal;" colspan=3 height=4| | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===PHYSICIANS' NOTES=== | |||
*'''Medical Officer:''' | |||
*'''Medical Assessment:''' | |||
|- | |||
|style="background:teal;"| | |||
|colspan=2| | |||
===COUNSELORS' NOTES=== | |||
*'''Counselor:''' | |||
*'''Psychological Assessment:''' | |||
|} | |||
__NOTOC__ | |||
[[Category:Medical Records]] | |||