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testappdfhsgaf
by Admin Ghost Sat Oct 13, 2012 10:46 pm

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1507 Slaughters Creek,
Cabin Creek, WV



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testappdfhsgaf

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testappdfhsgaf

Post  Admin Ghost on Sat Oct 13, 2012 10:46 pm



Lastname, Firstname

Your Playby Image Here, in IMG tags.


      D.O.B: dd/mm/yyyy
      AGE: 18-100
      GENDER: M/F
      STREET ADDRESS: House Number & Street
      TOWN/CITY: Town or City
      STATE: US State
      HEIGHT: In feet & Inches
      WEIGHT: In Pounds
      ETHNICITY: Caucasian/Hispanic/Asian, etc
      DISTINGUISHING MARKS: Any other distinguishing marks such as birth marks, moles, piercings and tattoos.


_____________________________________
Medical History

Do you have any ongoing medical issues for which you require treatment or medication?:

ANSWER HERE

Are you aware of any allergies? If so, please list allergy, age of onset and any medications or treatments you require or recieve:

ANSWER HERE

Have you had any surgeries or invasive procedures in the past? If yes, please list reason and approximate age of procedure:

ANSWER HERE

Do you take any medications or supplements daily? Do you follow any treatment plans? Please list medications or treatments, and reasons below:

ANSWER HERE

Do you use tobacco, consume alcohol, or use any other drugs including street drugs and/or prescription medications not prescribed to you? If yes, please list number of packs a day, number of drinks a day, and/or drugs consumed below:

ANSWER HERE

_____________________________________
Psychiatric Screening

Please describe, to the best of your ability, your emotional and mental state of wellbeing:

ANSWER HERE

Have you been diagnosed with any psychiatric or psychological ailments? Please list any diagnoses below, and the treatments or medications prescribed to you. Please include name of medications, dosage, and number of doses per day:

ANSWER HERE

Have you ever been hospitalised or referred to regular outpatient care due to these ailments or associated incidents? If so, please note where, and at roughly what age:

ANSWER HERE

How have these ailments affected you and your life? Are there any major life instances you feel have been directly affected by these ailments, such as suicide attempts, criminal activities, etc?:

ANSWER HERE

What is your social life like? Do you have many friends or relationships? How are your family relationships?:

ANSWER HERE

Do you believe your life circumstances have contributed to any ailments? If so, what circumstances, and why do you feel they have contributed?:

ANSWER HERE

If you could change one past event that has happened to you, what would it be, and why?:

ANSWER HERE

Do you wish to rehabilitate from your ailment(s)? If so, how do you feel this would best be accomplished?:

ANSWER HERE

_____________________________________
Environmental History

Where did you grow up? Please list the location(s) and describe what it was like growing up there:

ANSWER HERE

What was your family life like? Did you spend much time with your parents? Do you have any siblings? If so, what are your relationships like?:

ANSWER HERE

What was school like? Did you have any problems? Did you enjoy school? What were your grades like?:

ANSWER HERE

Did you engage in any extracurricular activities, such as academic, artistic, or sporting clubs?:

ANSWER HERE

What was work like? Did you have any problems? Did you enjoy your work? What were your coworker relationships like?:

ANSWER HERE

Have you ever been convicted of a crime or misdemeanour? If yes, please explain, list conviction, and list any sentences associated with convictions:

ANSWER HERE

Lastly, please tell us about yourself. How do you feel about yourself and what you have done with your life? If you have committed crimes, how do you feel about those now? What are your hopes for the future?:

ANSWER HERE

_____________________________________
Out of Character Section

What are they not telling us? What secrets do they have to hide? What back story are we not hearing? This is where you can tell us all the things your character wouldn't put on an application, or others don't know.:

((Remember, if you put all their back story as a secret, we won't be able to admit them to Hallowsgate! This section is for secrets only, not the entire character history. We need most of the info in the main app so we can process it!)) ANSWER HERE

Your Nickname: ANSWER HERE
Your Chatango Screen Name: ANSWER HERE
Your Character's Playby: ANSWER HERE

_________________________________________________________________________________

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Admin Ghost
Admin

Posts : 23
Points : 21
Join date : 2010-08-26
Age : 33

Patient File
Assigned Ward:
Issues Group: Administration
Assigned Therapist:

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