hark! a medical form! (for transmigration 9)

[haruno]

PATIENT MEDICAL HISTORY

Name:
Age: ?? years
Sex: ??
Height: ??inch/cm
Weight: ??lbs/kg

[ ] Magical by nature/practices magic.
[ ] Can't have magic used on.
[ ] Contagious (see notes).

SPECIES NAME HERE

Average Lifespan:
Rate of Maturity:
Average age of Puberty:

Normal Diet:

Common Ailments:

Specific Notes: (healing factors, special needs, etc)

GENERAL HEALTH

All of the following sense-related questions are to be answered in comparison to an average Homo sapiens. Ask your medical provider for assistance in answering this section.

Blood Pressure: [ ] Average | [ ] Low | [ ] High

Vision: [ ] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced

If Enhanced, further explain:

Hearing: [ ] Deaf | [ ] Low | [ ] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive

If necessary, further explain:

Smell: [ ] Cannot Smell | [ ] Low | [ ] Average | [ ] High | [ ] Extremely Sensitive

If Extremely Sensitive, further explain:

Known Allergies:

Are there any potential complications with healing processes we should be aware of when treating you?:

Do you have a healing factor different from the average for your species? If so, explain how here:

Have you recently been screened for species, sex, and age specific cancer risks?:

Special notes on care: (Such as contagious diseases/conditions, special means of handling, special care taken in handling)

Record of Past Injuries:

Ship Health Records:

SEXUAL HEALTH

Have you ever been sexually active?:

Are you currently Sexually Active:

Have you recently been screened for STIs?:

Species specific sexually related health notes and/or issues:

Reproductive Health (skip if N/A)

Date of Last Menses/Estrus/Equiv (skip if n/a):

Number of pregnancies:

Number of pregnancies carried to term:

Age of first birth/hatching/etc. (if applicable):

Total number of births/hatching/etc.:

DRUGS AND MEDICATION

Are you or should you be on any prescribed medication? If so, list below:

Have you taken any recreational or non-prescribed drugs or substances in the past? Is so, please list them and their frequency of use below:

Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below:

PATIENT MEDICAL HISTORY
Name:	Age: ?? years	Sex: ??	Height: ??inch/cm	Weight: ??lbs/kg
[ ] Magical by nature/practices magic.	[ ] Can't have magic used on.		[ ] Contagious (see notes).
SPECIES NAME HERE
Average Lifespan:	Rate of Maturity:		Average age of Puberty:
Normal Diet: Common Ailments: Specific Notes: (healing factors, special needs, etc)
GENERAL HEALTH
All of the following sense-related questions are to be answered in comparison to an average Homo sapiens. Ask your medical provider for assistance in answering this section.
Blood Pressure: [ ] Average | [ ] Low | [ ] High
Vision: [ ] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced
If Enhanced, further explain:
Hearing: [ ] Deaf | [ ] Low | [ ] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive
If necessary, further explain:
Smell: [ ] Cannot Smell | [ ] Low | [ ] Average | [ ] High | [ ] Extremely Sensitive
If Extremely Sensitive, further explain:
Known Allergies: Are there any potential complications with healing processes we should be aware of when treating you?: Do you have a healing factor different from the average for your species? If so, explain how here: Have you recently been screened for species, sex, and age specific cancer risks?: Special notes on care: (Such as contagious diseases/conditions, special means of handling, special care taken in handling) Record of Past Injuries: Ship Health Records:
SEXUAL HEALTH
Have you ever been sexually active?: Are you currently Sexually Active: Have you recently been screened for STIs?: Species specific sexually related health notes and/or issues:
Reproductive Health (skip if N/A)
Date of Last Menses/Estrus/Equiv (skip if n/a): Number of pregnancies: Number of pregnancies carried to term: Age of first birth/hatching/etc. (if applicable): Total number of births/hatching/etc.:
DRUGS AND MEDICATION
Are you or should you be on any prescribed medication? If so, list below: Have you taken any recreational or non-prescribed drugs or substances in the past? Is so, please list them and their frequency of use below: Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below: