Phoenix Vanguard Medical Division

Patient Intake Form

Fill out as much or as little information as you'd like. Irrelevant fields may be left blank.

IN CHARACTER INFORMATION

Patient Information

person Patient Name

groups Race

wc Gender

cake Age

Emergency Contact

contact_phone Name

people Relationship

mail Contact Method

Reason for Visit

report_problem Presenting Complaint/Injury

healing Current Symptoms

Pain Fever/Chills Nausea/Vomiting Dizziness/Disorientation Bleeding Difficulty Breathing Loss of Consciousness Other

warning Recent Exposures

Combat Voidsent Encounter Primal Encounter Poisonous Substances Extreme Temperatures Overaspected Crystals Other

Pre-Existing Conditions

favorite Chronic Illness

accessibility Previous Injuries

do_not_disturb Known Allergies

medication Current Medications

auto_awesome Aetheric Abnormalities

Authorization for Treatment

I authorize the Phoenix Vanguard medical staff to provide necessary medical treatment, including but not limited to: examination, diagnostic procedures, medication administration, surgical intervention, and aetheric healing. I understand that I may refuse specific treatments and that I will be informed of procedures when practical.

draw Patient or Witness Signature

event Date

OUT OF CHARACTER INFORMATION

assessment Severity Assessment

Minor (surface wounds, common illness, routine check) Moderate (significant injury, uncommon illness, requires monitoring) Severe (life-threatening, complex condition, intensive care required) Critical (immediate intervention required, high mortality risk) Not Sure/Other

schedule RP Goals and Timeline

Short-term: Single session resolution, full recovery expected Medium-term: 2-4 sessions, recovery with possible complications Long-term: Ongoing condition requiring extended care and follow-up Permanent: Condition will result in lasting effects

lightbulb Conceptual Development

I need help exploring this RP idea and would like collaborative assistance I know specifically what the issue is and how I'd like this RP to play out

flag Desired Outcomes (if any)

auto_stories Specific Plot Hooks/Story Elements (if any)

warning Are there specific triggers you'd like to avoid?