Travis Stewart

  
 orthoLA 
 CONFIDENTIAL PATIENT MEDICAL HISTORY 
 FOR OFFICE USE ONLY 
 HIGGINS ELIAS ELLENDER HILDENBRAND GREBER BORNE JOHNSON DUPLANTIS 
 HEIGHT 5.6 " 
 WEIGHT 764 lbs 
 AGE 65 
 BP 
 / 
 PULSE 
 TEMP 
 PATIENT NAME Nadine Buggage 
 BIRTHDATE 1995 October 03 SS# 769-76-1761 
 REASON FOR PRESENT VISIT Fall 
 AFFECTED 
 SIDE: DECET RIGHT DISATERAL DATE OF INJURY 2018 May 28 
 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 May 30 Dr. Justin Tenney 
 Unit 9742 Box 9223
DPO AE 01991 Phone: 250-764-5226 Fax: 497-630-4265 www.ortho-la.com
