patient template

[Lexi]

GENERAL INFORMATION

name: Last, First
age: written out
date of birth:
sex:
short description of yourself:

MEDICAL INFORMATION

Diagnosis ( If Any ):
any medication you're on:
dosage:
how often do you take it:
do you take it as prescribed?:
do you have any allergies?:
other medical issues?: (diabetes, heart issues, physical issues?)

PSYCHIATRIC INFORMATION

do you or have you ever suffered from ~

insomnia or lack of sleep?:
nightmares?:
nervousness?:
depression?:
substance abuse?:
black outs?:
hallucinations?:

have you ever ~

caused physical harm to yourself or others?:
been abused or abused someone else?:
used prescribed drugs that weren't for you?:
run away from home?:
forced yourself to get sick?:
tried to commit suicide?:

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OTHER QUESTIONS

do you live with your parents?:
if yes, are either a step parent?:
do you have any siblings?:
if yes, how old?:
do they treat you like a sibling should?:
are you out of high school?:
if yes, are you in college?:
do you have friends?:
do you think they were really friends?:
what was school like for you?:
how did people treat you?:
have you ever been in trouble with the law?:
if yes, what for?:
have you ever been to any other institute?:
if yes, what for?:
did you check yourself into riverside institute?:
if no, who did?:

do you think you should be at riverside institute?:
If no, why?:

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OOC QUESTIONS

alias/name:
age:
rp experience:
anything else?: