New Patient Intake Form
Instructions: Please answer the questions, then return this form to the woman at the desk.
My Japanese great-grandmother immigrated to California. She shed her birth name, Kino, and replaced it with Mary. She married a white American Navy man. He went off to fight in World War II, while Mary and her two young children were taken to a Japanese Internment Camp.
Now, my middle name is Mary, not Kino. I never met this woman—she died before I was born. Nobody thinks “Japanese great-grandmother” when they hear “Mary.” They think “mother of Jesus” and also “Virgin.” Don’t even get me started on the Virgin Mary.
Caitlin, my first name, is the Irish form of Catherine, which means Purity. So far it’s looking like I’m a double virgin.
Vance, my English last name, means “dweller of bog” or “one who lives near the marshland.”
As far as I know, I am not Irish or English. I don’t know “what” all I am, besides Japanese and German. My family did not keep records. Some of them never asked their parents what they “were,” and then they died. Others were so crazy that I didn’t know whether or not to trust what they claimed. “You’re related to the Last Samurai,” my grandma used to say. Why is Tom Cruise in that movie? “You’re related to a Blackfoot princess,” my grandma used to say, while we watched Disney’s Pocahontas. “And a Welsh princess, too.” Once I save $200 I will get 23 & Me, maybe. But it doesn’t seem very legit.
Caitlin Mary Vance: or, “Bog-Dwelling, Double-Virgin Mother of a Non-Japanese Male Deity.”
I tend to sleep my birthdays away.
I identify with SOME of the qualities associated with my astrological sign: I am curious, adaptable, and nervous. I am inconsistent, indecisive, restless. Cerebral, gentle, and affectionate. I contain two personalities in one. I forever seek a missing other half that in fact does not exist. I make too many wishes.
However, I do not feel like the life of the party. Aren’t Geminis supposed to be the life of the party?
You can find me reading in the pink chair with high walls like a womb.
Emergency Contact Information:
While in the midst of an emergency, I tend not to answer the phone.
Please list any health problems that you and/or members of your blood family have:
Brain cancer, lung cancer, COPD, heart disease, stroke, clinical depression, OCD, bipolar disorder, seizures, body dysmorphia, PTSD, insomnia, alcoholism, drug addiction, agoraphobia.
What do you eat for breakfast?
Coffee. Powdered, chocolate-flavored vitamins mixed with soymilk. Two yellow pills, one pink,
half a white.
How much do you drink?
I kind of hate alcohol, but I drink beers at poetry readings because it seems weird not to. They are always holding poetry readings at bars. I feel I always have to pay for the space I take up.
Do you smoke or use other tobacco products?
Years ago on the first day of school, the poetry teacher asked each student what we loved most. My real answer was humiliating. I made something up instead. My girlfriend at the time said “reading.”
Recently I went to a beautiful wedding on a beach. The next day I got a respiratory infection and coughed my way into a lost voice. I slept away the next two weeks. Never have I felt so useless. Never have I been so aware that my body is aging, and that part of aging is sickness.
I no longer enjoy cigarettes, because of their association with coughing. I don’t even smoke them when I’m drunk. Then again, I never get drunk anymore. My uncle died a few days ago. He hadn’t been able to breathe for a long time. He had a breathing machine like Darth Vader. Perhaps my favorite word from academia is post-human.
Are you currently pregnant?
No. I wish, but I need to procure money first and I don’t know how to do that. Plus, several people have suggested that I’m too crazy to have a child. The child will be crazy, too, they fear.
Have you ever been pregnant?
Would you like to speak to someone about birth control today?
Oh, yes—Congress, the Supreme Court, the White House, extremist religious groups, medical researchers, and all the men who have sex with women.
When was the date of your last menstrual period?
I couldn’t be more proud to say that I’m finally synced up with the moon. When she is full
and bright, I am bleeding.
Can you start with 100, then subtract 7 over and over and tell me what number you end up with?
No, thanks. You can just mark me down as impaired, or whatever.
Do you have any plans to carry out suicide or murder?
Certainly not. I would never kill myself unless I knew I would otherwise face a worse death. For instance, if someone was about to chop me into pieces and then eat the pieces in front of me (and they’d eat my eyes last), and I saw a gun within reach but the gun was enchanted so that I couldn’t use it to shoot the murderer, I could only use it to shoot myself, and there was no possibility of escaping the scenario, I’d shoot myself in the head because I know exactly the right way to do it so you actually die, you don’t just cause yourself a lot of pain and wake up later in a hospital bed with tubes in all your orifices, and I don’t like that I know the best way to successfully die but I do, someone told it to me. I won’t be the one to tell it to you, doctor, nurse, Sally, or whoever is reading this form. But it would be pretty easy to look up, if you’re curious.
More realistically, though, say I live to old age and then I’m diagnosed with some terminal, terrible illness like COPD. Rather than just letting the suffering get worse and worse until I shrivel into a raisin and die alone in a hospital while my future grown children are out for a few minutes sitting in line at a Chick-Fil-A drive-thru, I might prefer, upon being diagnosed with some shitty illness, to just go to a wonderful beach with all my friends and family (the ones who are still alive) and all their dogs. We could have a potluck party and a poetry reading on the beach, perhaps take some MDMA, light tiki torches, bounce in a bouncy castle, then everyone would go around in a circle and say their favorite things about me. Then I’d take whatever kind of poison is closest to painless, and float out to sea on a little raft clutching a bouquet of bleeding hearts, my favorite flower, and mermaids could eat my corpse.
Or perhaps I’d also kill myself if I knew I were about to face something even worse than death—whatever death even is. These days they say God’s not real, therefore death is only oblivion, or nothing, or darkness.
I would never kill someone else unless it was in defense of someone I loved or probably even self-defense, or in defense of the good of the world…I hope I wouldn’t get all French Revolution though. I really do wonder how the world may have been different if the damn French Revolution people had just been a little less sadistic, raping both living people and corpses, chopping off the head of Marie Antoinette’s best friend, then parading it on a stick outside Marie Antoinette’s window. A murderer on one of those Netflix documentary series about murderers describes “not being able to” kill his friend, but then “stepping past the part [of himself] that wouldn’t let [him] do it.”
Is the thing preventing us from killing just some invisible wall you can simply step through?
Have you ever started a fire?
In Nick’s backyard one summer, near a pile of dry fallen leaves, we held a long lighter in front of a Super Soaker filled with gasoline we took from his dad’s garage stash. That was one incident in our year of pyromania. We, at least I, never hoped for any real damage, it’s just that it was summer—school was out, my mother was at work, my sister was locked in the basement, doing whatever she did all day on the internet. I was lonely, too old to find friends in the stuffed rabbit Daisy or the dinosaur Mary. I’ve always had an inexplicable aversion to technology. This makes me wonder if I’m less evolved than other people. I was too young for drugs and too young for sex. Fire was about right for my age.
What kind of insurance do you have?
The cheapest option on the Obamacare website.
What is the meaning of this statement? “Those who live in glass houses should not throw stones.”
I’ve never heard this statement in my life. I’ll suppose it means: being self-destructive does not make you cool.
Please sign your name in the space below, then kindly return this form to the woman at the desk. Thank you.
Image Credit: Pavel Chelishchyov “Hide and Seek” (1942)
Caitlin Vance is a poet and fiction writer currently living in Lafayette, LA, where she is a PhD Candidate in English & Creative Writing. Her poetry book, Think of the World as a Mirror Maze, was published by Stubborn Mule Press in 2019, and her poetry chapbook, The Little Cloud, was published by dancing girl press in 2018. Her book of short fiction, The Paper Garden & Other Stories, is forthcoming in 2021 from 7.13 Books. Her poems and stories have appeared in Tin House, The Southern Review, The Collagist (now The Rupture), ZYZZYVA, Washington Square Review, New Ohio Review, The Literary Review, and other magazines. She received her MFA from Syracuse University.