[Institute of Regression & Behavioral Health]

MEDICAL RECORD

PATIENT INFORMATION
Full Name: emptyteaspoon (but you can call me A)
Age: 30
Gender: F
Location: New England, USA
Treatment location: virtual, but will travel for specialist
INSURANCE INFORMATION

Insurance Provider: PinnacleCare Health Policy Number: ABU893041372
MEDICAL HISTORY

Past Medical Conditions: nighttime incontinence, constipation, bladder emptying issues, frequent urination, muscle pain and weakness, joint issues, fatigue, behavioral issues, emotional/mental health issues, and substance abuse (nicotine vaping)

• Current Medications: psychiatric medications, pending additional treatment
• Surgical History: wisdom teeth
• Procedure History: colonoscopy, rectal contrast CT, and ECT

CHIEF COMPLAINT
Patient's main reason for seeking medical attention: pt is seeking care to help manage and guide her day-to-day life and health choices. She also is seeking assistance with her bladder and bowel issues but is primarily looking for a physician or alternative practitioner who can provide a thorough treatment plan that they will guide the patient through via Telehealth with in-person appointments as necessary until pt’s quality of life improves.
PHYSICAL EXAMINATION
Assessment complete, full physical examination TBD
General Appearance: 5’5”, 185 lb, brunette, long straight hair, 34C bra size, size 12/L/XL, hazel eyes, several piercings and tattoos
Systems Examined: all systems need a full examination at this time
PATIENT'S CONSENT
I, emptyteaspoon, acknowledge that I have reviewed and discussed the information in this medical record with my healthcare provider, and I consent to the proposed treatment plan and any necessary diagnostic tests. This form notarizes my consent to be contacted by medical professionals who feel they can adequately provide treatment. Correspondence will be initiated by these medical professionals via direct message.

Patient's Signature: ET Date: today

HEALTHCARE PROVIDER INFORMATION
Provider's Name: [YOUR NAME] License Number: [XXX YOUR #]
Contact Information: [YOUR REDDIT USERNAME]
Signature: YN Date: today

[End of Medical Record]