Diane Nelson

  
 orthoLA 
 CONFIDENTIAL PATIENT MEDICAL HISTORY 
 FOR OFFICE USE ONLY 
 HIGGINS ELIAS ELLENDER HILDENBRAND GREBER BORNE JOHNSON DUPLANTIS 
 HEIGHT 5.6 " 
 WEIGHT 644 lbs 
 AGE 85 
 BP 
 / 
 PULSE 
 TEMP 
 PATIENT NAME Nadine Buggage 
 D.O.B 1998 February 16 SS# 649-64-1641 
 REASON FOR PRESENT VISIT Fall 
 AFFECTED 
 SIDE: DECET RIGHT DISATERAL doi 2018 May 02 
 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 - 2015 October 04 Dr. Justin Tenney 
 257 Page Meadows
East Davidmouth, AL 24284 Phone: 512-539-9237 Fax: 471-478-9606 www.ortho-la.com
