Kristina Hunter

  
 orthoLA 
 CONFIDENTIAL PATIENT MEDICAL HISTORY 
 FOR OFFICE USE ONLY 
 HIGGINS ELIAS ELLENDER HILDENBRAND GREBER BORNE JOHNSON DUPLANTIS 
 HEIGHT 5.6 " 
 WEIGHT 484 lbs 
 AGE 33 
 BP 
 / 
 PULSE 
 TEMP 
 PATIENT NAME Nadine Buggage 
 DATE OF BIRTH 07/1995/28 SS# 489-48-1481 
 REASON FOR PRESENT VISIT Fall 
 AFFECTED 
 SIDE: DECET RIGHT DISATERAL Injury Date 03/2020/29 
 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 - 09/2023/23 Dr. Justin Tenney 
 3417 Tammy Islands Apt. 648
Brentville, LA 66808 Phone: 798-608-7803 Fax: 692-698-7885 www.ortho-la.com
