PATIENT MEDICAL HISTORY | ||||
Name: Steve Burnside | Age: ~18 years | Sex: Male | Height: 68 inches/ 172 cm | Weight: 149 lbs / 67 kg |
[ ] Magical by nature/practices magic. | [ ] Can't have magic used on. | [X] Contagious (see notes). | ||
Human (Veronica) | ||||
Average Lifespan: 60-80 years | Rate of Maturity: 18-20 years | Average age of Puberty: 13-16 years | ||
Normal Diet: Omnivorous Common Ailments: [List of common ailments goes here.] Specific Notes: - Patient is infected with the T-Veronica virus [Attachment: Notes on T-Veronica] |
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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. |
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Blood Pressure: [X] Average | [ ] Low | [ ] High | ||||
Vision: [X] Fine | [ ] Near Sighted | [ ] Far Sighted | [ ] Enhanced | ||||
If Enhanced, further explain: |
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Hearing: [ ] Deaf | [ ] Low | [X] Average | [ ] High Range | [ ] Low Range | [ ] Extremely Sensitive | ||||
If necessary, further explain: |
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Smell: [ ] Cannot Smell | [ ] Low | [X] Average | [ ] High | [ ] Extremely Sensitive | ||||
If Extremely Sensitive, further explain: |
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Known Allergies: Are there any potential complications with healing processes we should be aware of when treating you?: Yeah, my friggin' blood lights on fire. That's probably something you should be aware of. Do you have a healing factor different from the average for your species? If so, explain how here: If the virus is active I can heal from almost anything in a few seconds. So, uh... that shouldn't be a problem, right? Have you recently been screened for species, sex, and age specific cancer risks?: Cancer is the least of my goddamn worries, okay? Special notes on care: (Such as contagious diseases/conditions, special means of handling, special care taken in handling) - Patient is infected with T-Veronica virus, a highly volatile mutagen which causes a variety of side effects. Left unchecked, patient is at risk of mutation into "Tyrant." Extreme care must be taken when working with patient. - Blood ignites upon exposure to oxygen. Burns from blood are at risk of infection from virus, please use extreme caution in handling patient's injuries. Record of Past Injuries: Multiple gunshot wounds; malnutrition; abdominal impalement Ship Health Records: Veronica mutation, stage 1 (skin discoloration); Veronica mutation, stage 2 (skin discoloration, iris discoloration, mutation of hand and finger bones, development of inhuman extremities); Veronica mutation, stage 3 (full body mutation and mental state alteration); multiple gunshot wounds |
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SEXUAL HEALTH | ||||
Have you ever been sexually active?: NO! Are you currently Sexually Active: NO NO NO Have you recently been screened for STIs?: NO!! Species specific sexually related health notes and/or issues: |
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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.: |
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DRUGS AND MEDICATION | ||||
Are you or should you be on any prescribed medication? If so, list below: - Biweekly T-Veronica treatments in Contagion to nullify infection and mutation risk 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 |