I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [x] Ms.
- [] Other
Kara
Middle Name: (optional)
Last Name:
Bustamante
Gender: (select one)- [] Male
- [x] Female
03/04/2002
Address:
195 Spanish Avenue - Floor 4, Room 1
ZIP / Postal Code:
55555
II. CONTACT INFORMATION
- Phone Type: (select one)
- [x] Mobile
- [] Home
- [] Work
- [] Other
38457170
Email:
[email protected] [purplehuman]
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [x] Yes
- [] No
- [x] Yes
- [] No
Kara Bustamante has been diagnosed with Autism and Schizophrenia in the past.
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
Kara has been having several episodes because of her schizophrenia. She is at risk of harming herself or others due to her "hunting against the Krollians". She describes them as aliens that come from space to exterminate humans. Note: This application was made by a friend, because Kara doesn't know how to fill this. All of this was made based on her answers.
Is this condition or injury related to work?- [] Yes
- [x] No
- [] Yes
- [x] No
- [] Medical
- [x] Psychology
- [x] 06/08/2022 - All Day
[x] 07/08/2022 - After 14:00
[x] 08/08/2022 - All Day
ANSWER