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Hallowsgate Hospital,
1507 Slaughters Creek,
Cabin Creek, WV



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 Patient Application Template

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PostSubject: Patient Application Template   Fri May 25, 2012 7:57 pm

PATIENT APPLICATION TEMPLATE & RULES
_____________________________________

Before you begin your application, please spare a moment to read the following application rules and guidelines. Failure to do so may result in your application being denied before it even gets to review! You have been warned.

  • Please make sure you have read all of our required reading before you begin the application. Please pay specific attention to the forum rules and the character creation threads.

  • When you post your application, please do so in the application process board. Title it with your character's first and last name only. For example: John Doe.

  • Do not alter the application code in any way. Do not use blinding colours. If you wish to differentiate some parts, you may put them in italics, bold, etc.

  • Anything you put in the OOC section will be assumed to be unknown, so if all your info is here, then Hallowsgate won't have any reason to admit the character. The OOC section is for dirty little secrets that no-one knows about only.

  • Please try to answer all questions on the application thoroughly. You may have to use a little artistic license if your character is reluctant to speak. We need to know everything so that they can be approved, so poke them with a spork if you must. Alternately, you may have a psychiatrist or guardian fill out some sections, but make sure to differentiate those parts (with italics for example) and mention who is writing them, on the app.

  • Please have your character fill out the application as if it is a written application.

  • Please do not post work in progress applications.

  • Please keep your application image within reasonable size bounds. Ideally, 400px by 400px should be the very maximum size.

  • Don't panic if you get a pending notice! A lot of applications get pended, especially for first-time players! It doesn't mean we hate you, and we're just trying to give you some guidelines and pointers, to help you fit seamlessly into the realism we're going for. So take a deep breath and remember, we're not picking on you!

  • Lastly: Have Fun! Don't take anything too seriously, and don't fret. Remember, it's just a game!

_____________________________________




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

Code:

[center][img]http://imageshack.us/a/img689/8538/appgz.png[/img]

[size=24][color=#787878]Lastname, Firstname[/color][/size]

Your Playby Image Here, in IMG tags.  [/center]

[list][list]
[color=#787878][b] D.O.B:[/b][/color] dd/mm/yyyy
[color=#787878][b] AGE:[/b][/color] 18-100
[color=#787878][b] GENDER:[/b][/color] M/F
[color=#787878][b] STREET ADDRESS:[/b][/color] House Number & Street
[color=#787878][b] TOWN/CITY:[/b][/color] Town or City
[color=#787878][b] STATE:[/b][/color] US State
[color=#787878][b] HEIGHT:[/b][/color] In feet & Inches
[color=#787878][b] WEIGHT:[/b][/color] In Pounds
[color=#787878][b] ETHNICITY:[/b][/color] Caucasian/Hispanic/Asian, etc
[color=#787878][b] DISTINGUISHING MARKS:[/b][/color] Any other distinguishing marks such as birth marks, moles, piercings and tattoos.
[/list][/list]

 [center]_____________________________________
[size=16][color=#787878]Medical History[/color][/size][/center]

[color=#787878][b]Do you have any ongoing medical issues for which you require treatment or medication?:[/b][/color]

ANSWER HERE

[color=#787878][b]Are you aware of any allergies? If so, please list allergy, age of onset and any medications or treatments you require or recieve:[/b][/color]

ANSWER HERE

[color=#787878][b]Have you had any surgeries or invasive procedures in the past? If yes, please list reason and approximate age of procedure:[/b][/color]

ANSWER HERE

[color=#787878][b]Do you take any medications or supplements daily? Do you follow any treatment plans? Please list medications or treatments, and reasons below:[/b][/color]

ANSWER HERE

[color=#787878][b]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:[/b][/color]

ANSWER HERE

[center]_____________________________________
[size=16][color=#787878]Psychiatric Screening[/color][/size][/center]

[color=#787878][b]Please describe, to the best of your ability, your emotional and mental state of wellbeing:[/b][/color]

ANSWER HERE

[color=#787878][b]Have you been diagnosed with any psychiatric or psychological ailments? Please list any diagnoses below, [u]and[/u] the treatments or medications prescribed to you. Please include name of medications, dosage, and number of doses per day:[/b][/color]

ANSWER HERE

[color=#787878][b]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:[/b][/color]

ANSWER HERE

[color=#787878][b]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?:[/b][/color]

ANSWER HERE

[color=#787878][b]What is your social life like? Do you have many friends or relationships? How are your family relationships?:[/b][/color]

ANSWER HERE

[color=#787878][b]Do you believe your life circumstances have contributed to any ailments? If so, what circumstances, and why do you feel they have contributed?:[/b][/color]

ANSWER HERE

[color=#787878][b]If you could change one past event that has happened to you, what would it be, and why?:[/b][/color]

ANSWER HERE

[color=#787878][b]Do you wish to rehabilitate from your ailment(s)? If so, how do you feel this would best be accomplished?:[/b][/color]

ANSWER HERE

[center]_____________________________________
[size=16][color=#787878]Environmental History[/color][/size][/center]

[color=#787878][b]Where did you grow up? Please list the location(s) and describe what it was like growing up there:[/b][/color]

ANSWER HERE

[color=#787878][b]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?:[/b][/color]

ANSWER HERE

[color=#787878][b]What was school like? Did you have any problems? Did you enjoy school? What were your grades like?:[/b][/color]

ANSWER HERE

[color=#787878][b]Did you engage in any extracurricular activities, such as academic, artistic, or sporting clubs?:[/b][/color]

ANSWER HERE

[color=#787878][b]What was work like? Did you have any problems? Did you enjoy your work? What were your coworker relationships like?:[/b][/color]

ANSWER HERE

[color=#787878][b]Have you ever been convicted of a crime or misdemeanour? If yes, please explain, list conviction, and list any sentences associated with convictions:[/b][/color]

ANSWER HERE

[color=#787878][b]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?:[/b][/color]

ANSWER HERE

[center]_____________________________________
[size=16][color=#787878]Out of Character Section[/color][/size][/center]

[color=#787878][b]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.:[/b][/color]

 ((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

[color=#787878][b]Your Nickname:[/b][/color] ANSWER HERE
[color=#787878][b]Your Chatango Screen Name:[/b][/color] ANSWER HERE
[color=#787878][b]Your Character's Playby:[/b][/color] ANSWER HERE
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