Natalie Crane

  
 orthoLA 
 CONFIDENTIAL PATIENT MEDICAL HISTORY 
 FOR OFFICE USE ONLY 
 HIGGINS ELIAS ELLENDER HILDENBRAND GREBER BORNE JOHNSON DUPLANTIS 
 HEIGHT 5.6 " 
 WEIGHT 574 lbs 
 AGE 62 
 BP 
 / 
 PULSE 
 TEMP 
 PATIENT NAME Nadine Buggage 
 dob 98/02/04 SS# 579-57-1571 
 REASON FOR PRESENT VISIT Fall 
 AFFECTED 
 SIDE: DECET RIGHT DISATERAL date of injury 23/04/13 
 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 - 19/02/28 Dr. Justin Tenney 
 64031 Lawson Key
Port Jill, DC 32953 Phone: 244-639-5630 Fax: 220-885-7054 www.ortho-la.com
