Patient Application form

[Angel]

Surname, First Name Second Name

[image code here]

Name:
Name and surname here.
Date of birth and age:
Day, Month, Age
Gender:
Male/Female/Transgender
Room required:
Male, Female or Unisex
Previous Facility:
Previous facility character attended.
Time at the facility pending arrival here:
How long were they in the facility for?
Previous Doctor:
Who was their main doctor?
Current Medication:
Use the internet to search for the appropriate drug to use here please
Birth father Name:
If they don’t know put N/A
Birth Mother Name:
If they don’t know put N/A
Diagnosed Disorder:
What do they have? Here you have to remember that the points you mention below this will have to co-ordinate with the disorder.
Blood Type:
What blood type are they.
Allergies:
N/A if there are none. Allergies like hospital worthy allergies. Not what they DO NOT like.
Medical Condition:
Any medical conditions to be aware of like a Aids, Cancer... something milder... Please be the latter.
Current Medication:
The above question’s medication. If you have no medical conditions write not applicable
Any surgeries in the last six months?

Patient presents with:

Symptoms/Behavioural disorder:

(Things your character does that would help identify their disorder)

History:

• Alcoholic parents?
  
• Drug Addicted Parents?
  
• Violent behaviours toward others?
  
• Explain in brief sentences what happened for your character to be the way they are
  
• Criminal records?
  
• Anger issues?
  
• Suicide attempts?
  
• Anything you might believe is important.
  
• Not a full history.
  
• Just brief pieces.
  

Signed: (guardian Name/Doctor Name/Parent name)

Out Of Character

Player name:
Player age:
Player Years of Experience:
Playby/Faceclaim Name:
How did you find us?


[center][size=4][i][u]Surname, First Name Second Name[/u][/i][/size][/center]


[center][image code here][/center]

[blockquote][b]Name:[/b]
Name and surname here.
[b]Date of birth and age:[/b]
Day, Month, Age
[b]Gender:[/b]
Male/Female/Transgender
[b]Previous Facility:[/b]
Previous facility character attended.
[b]Time at the facility pending arrival here:[/b]
How long were they in the facility for?
[b]Previous Doctor:[/b]
Who was their main doctor?
[b]Current Medication:[/b]
Use the internet to search for the appropriate drug to use here please
[b]Birth father Name:[/b]
If they don’t know put N/A
[b]Birth Mother Name:[/b]
If they don’t know put N/A
[b]Diagnosed Disorder:[/b]
What do they have? Here you have to remember that the points you mention below this will have to co-ordinate with the disorder.
[b]Blood Type:[/b]
What blood type are they.
[b]Allergies:[/b]
N/A if there are none. Allergies like hospital worthy allergies. Not what they DO NOT like.
[b]Medical Condition:[/b]
Any medical conditions to be aware of like a Aids, Cancer... something milder... Please be the latter.
[b]Current Medication:[/b]
The above question’s medication. If you have no medical conditions write not applicable
[b]Any surgeries in the last six months?[/b]
[/blockquote]

[b][u]Patient presents with:[/u][/b]

[b]Symptoms/Behavioural disorder:[/b]

(Things your character does that would help identify their disorder)

[b]History: [/b]
[ul]
[li] Alcoholic parents?
[/li][li] Drug Addicted Parents?
[/li][li] Violent behaviours toward others?
[/li][li] Explain in brief sentences what happened for your character to be the way they are
[/li][li] Criminal records?
[/li][li] Anger issues?
[/li][li] Suicide attempts?
[/li][li] Anything you might believe is important.
[/li][li] Not a full history.
[/li][li] Just brief pieces.
[/li][/ul]

[u]Signed:[/u] (guardian Name/Doctor Name/Parent name)

[b][u]Out Of Character[/u][/b]

[b]Player name: [/b]
[b]Player age:[/b]
[b]Player Years of Experience: [/b]
[b]Playby/Faceclaim Name:[/b]
[b]How did you find us?[/b]