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PATIENT MEDICAL HISTORY
Name: Eva Salazar Age: 48 years Sex: F Height: 5'6inch Weight: 152lbs/kg
[ ] Magical by nature/practices magic. [ ] Can't have magic used on. [ ] Contagious (see notes).
HUMAN
Average Lifespan: 73 Rate of Maturity: 18 years Average age of Puberty: 12 years

Normal Diet: Standard human diet. See file.

Common Ailments: Common human illnesses. 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: [ ] Fine | [ ] Near Sighted | [ ] Far Sighted | [x] Enhanced
If Enhanced, further explain: Reading glasses.
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: No.

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

Special notes on care: No treatment to neck or ear injuries unless emergency.

Record of Past Injuries: Extensive physical trauma (see file). Was in physical therapy on homeworld; discontinued.

Ship Health Records: Demonic possession (exorcised). See file.
SEXUAL HEALTH
Have you ever been sexually active?: Yes.
Are you currently Sexually Active: No.
Have you recently been screened for STIs?: Yes.

Species specific sexually related health notes and/or issues: One pregnancy carried to term (age 28).
Date of Last Menses/Estrus/Equiv (skip if n/a): Within the last month.
Number of pregnancies: One.
Number of pregnancies carried to term: One.
Age of first birth/hatching/etc. (if applicable): 28.
Total number of births/hatching/etc.: One.
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: Alcohol, recreational, 5-10 glasses weekly.

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Eva Salazar

December 2011

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