[MEDICAL] AMAHLE HOPE MTHEMBU

[Sarah Baker]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [] Mrs.
  • [X] Ms.
  • [] Other
  First Name:
  AMAHLE
  
  Middle Name: (optional)
  HOPE
  
  Last Name:
  MTHEMBU
  
  Gender: (select one)
  • [] Male
  • [X] Female
  Date of Birth:
  02/OCT/2000
  
  Address:
  2362 Bridge Street - Floor 1, Room 1
  
  ZIP / Postal Code:
  (( uh ))
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  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

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• Has the patient been seen at Pillbox Hill Medical Center in the past?
  • [X] Yes
  • [] No
  Does the patient have a diagnosis?
  • [X] Yes
  • [] No
  If so, please describe:
  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
  Is this condition or injury related to an auto accident?
  • [] Yes
  • [X] No
  Department:
  • [X] Medical
  • [] Psychology
  Dates & Times for Appointment: (list your available dates and times in the next 7 days - use more lines if needed and mark with an 'X' your preferred one. Note that we cannot guarantee exact scheduling, but we will do our best to accommodate the patient's wishes.)
  • [X] 18:00 - 01:30am, any day between/on 13/NOV - 31/NOV.
  Preferred Doctor for Appointment: (check the list of doctors here and pick one based on personal preference. Note that this is optional and if you don't choose one, one will be automatically assigned to you.)
  Any.