I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [X] Ms.
- [] Other
AMAHLE
Middle Name: (optional)
HOPE
Last Name:
MTHEMBU
Gender: (select one)- [] Male
- [X] Female
02/OCT/2000
Address:
2362 Bridge Street - Floor 1, Room 1
ZIP / Postal Code:
(( uh ))
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
28985848
Email:
[email protected] (( "Afthaire" on forums. This is a real email address, but as with any forum PMs, let me know if you use it! ))
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [X] Yes
- [] No
- [X] Yes
- [] No
Acute stress disorder*, severe nut and opioid allergy, prior admission for bacterial meningitis.
(( *This is what I was RPing after a recent event, but it was never actually diagnosed in roleplay, so feel free to retcon if necessary! ))
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
My headaches and jaw pain are ongoing, as well as the ear ache. I don't think the antibiotics I was prescribed are working.
Is this condition or injury related to work?- [] Yes
- [X] No
- [] Yes
- [X] No
- [X] Medical
- [] Psychology
- [X] 18:00 - 01:30am, any day between/on 13/NOV - 31/NOV.
Any.