Health Eval Form
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PATIENT MEDICAL HISTORY
Name: Howard Bassem
Age: 15 years
Sex: M
Height: 5'3inch
Weight: 103lbs
[ ] Magical by nature/practices magic.
[ ] Can't have magic used on.
[ ] Contagious (see notes).
HUMAN
Average Lifespan: 69.8
Rate of Maturity: 18 years
Average age of Puberty: 12 years
Normal Diet: Standard human diet (omnivorous). See file.
Common Ailments: Common human illness. See file.
Specific Notes: None.
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 | [x] High
Vision: [x] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced
If Enhanced, further explain:
Hearing: [ ] Deaf | [ ] Low | [x] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive
If necessary, further explain:
Smell: [ ] Cannot Smell | [ ] Low | [x] Average | [ ] High | [ ] Extremely Sensitive
If Extremely Sensitive, further explain:
Known Allergies: None.
Are there any potential complications with healing processes we should be aware of when treating you?: None.
Do you have a healing factor different from the average for your species? If so, explain how here: None.
Have you recently been screened for species, sex, and age specific cancer risks?: Yes.
Special notes on care: Vaccinations up to date for Earth-American human circa 2008 in relevant verses. See file for details.
Record of Past Injuries or Illnesses: History of childhood accidents and injuries, see file. Chicken pox at age 7. Severe malnutrition at ages 13-15.
Ship Health Records: Bite wound on foot (Epicurea, treated).
SEXUAL HEALTH
Date of Last Menses/Estrus/Equiv (skip if n/a): n/a
Have you ever been sexually active?: No.
Are you currently Sexually Active: No.
Have you recently been screened for STIs?: No.
Species specific sexually related health notes and/or issues: None.
DRUGS AND MEDICATION
Are you or should you be on any prescribed medication? If so, list below: None.
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: None.
Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below: None.
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PATIENT MEDICAL HISTORY
Name: Howard Bassem
Age: 15 years
Sex: M
Height: 5'3inch
Weight: 103lbs
[ ] Magical by nature/practices magic.
[ ] Can't have magic used on.
[ ] Contagious (see notes).
HUMAN
Average Lifespan: 69.8
Rate of Maturity: 18 years
Average age of Puberty: 12 years
Normal Diet: Standard human diet (omnivorous). See file.
Common Ailments: Common human illness. See file.
Specific Notes: None.
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 | [x] High
Vision: [x] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced
If Enhanced, further explain:
Hearing: [ ] Deaf | [ ] Low | [x] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive
If necessary, further explain:
Smell: [ ] Cannot Smell | [ ] Low | [x] Average | [ ] High | [ ] Extremely Sensitive
If Extremely Sensitive, further explain:
Known Allergies: None.
Are there any potential complications with healing processes we should be aware of when treating you?: None.
Do you have a healing factor different from the average for your species? If so, explain how here: None.
Have you recently been screened for species, sex, and age specific cancer risks?: Yes.
Special notes on care: Vaccinations up to date for Earth-American human circa 2008 in relevant verses. See file for details.
Record of Past Injuries or Illnesses: History of childhood accidents and injuries, see file. Chicken pox at age 7. Severe malnutrition at ages 13-15.
Ship Health Records: Bite wound on foot (Epicurea, treated).
SEXUAL HEALTH
Date of Last Menses/Estrus/Equiv (skip if n/a): n/a
Have you ever been sexually active?: No.
Are you currently Sexually Active: No.
Have you recently been screened for STIs?: No.
Species specific sexually related health notes and/or issues: None.
DRUGS AND MEDICATION
Are you or should you be on any prescribed medication? If so, list below: None.
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: None.
Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below: None.