Medical Form
PATIENT MEDICAL HISTORY
Name: Midna
Age: 20 years
Sex: female
Height: 3’3”/100cm
Weight: 20 lbs/9kg
[x] Magical by nature/practices magic.
[ ] Can't have magic used on.
[ ] Contagious (see notes).
SPECIES NAME HERE
Average Lifespan: ~70
Rate of Maturity: Normal
Average age of Puberty: 13
Normal Diet: Normal human diet
Common Ailments: Colds, occasional flu
Specific Notes: Patient is an imp. [detailed workup]
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: [x] Average | [ ] Low | [ ] 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?: No.
Do you have a healing factor different from the average for your species? If so, explain how here: No.
Have you recently been screened for species, sex, and age specific cancer risks?: No.
Special notes on care: br>
Record of Past Injuries: N/A
Ship Health Records: N/A
SEXUAL HEALTH
Date of Last Menses/Estrus/Equiv (skip if 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:
DRUGS AND MEDICATION
Are you or should you be on any prescribed medication? If so, list below: No.
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: No.
Do you currently take any recreational or non-prescribed drugs or substances? Is so, please list them and their frequency of use below: No.