Hunter Cortez

  
 orthoLA 
 CONFIDENTIAL PATIENT MEDICAL HISTORY 
 FOR OFFICE USE ONLY 
 HIGGINS ELIAS ELLENDER HILDENBRAND GREBER BORNE JOHNSON DUPLANTIS 
 HEIGHT 5.6 " 
 WEIGHT 654 lbs 
 AGE 33 
 BP 
 / 
 PULSE 
 TEMP 
 PATIENT NAME Nadine Buggage 
 DATE OF BIRTH 94-09-17 SS# 659-65-1651 
 REASON FOR PRESENT VISIT Fall 
 AFFECTED 
 SIDE: DECET RIGHT DISATERAL DATE OF INJURY 16-07-22 
 ARE 
 YOU 
 DRIGHT-HANDED 
 LEFT-HANDED ARE YOU CURRENTLY PREGNANT 
 YES 
 NO OCCUPATION 
 How did Injury occur? 
 Where did injury occur? 
 PAST SURGICAL/HOSPITALIZATION HISTORY (Please Include: Date, Surgery/Illness, Doctor, Facility) 
 Sinus - 17-07-11 Dr. Justin Tenney 
 1345 Duran Islands Suite 505
South Amanda, HI 50551 Phone: 470-794-8859 Fax: 631-884-3372 www.ortho-la.com
