Medical History

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Has patient been previously admitted to emergency treatment facility? [X] Yes [ ] No

If yes, specify date, facility and brief description of injury/treatment:

11/21/61: Bellaire Medical Center — 4-stitches to forehead; fall from changing table.

03/15/63: Bellaire Medical Center — 6-stitches to right eyebrow; impact from swing seat.

08/21/64: Bellaire Medical Center — ankle fracture (right); pushed from tree house.

06/02/66: Bellaire Medical Center — observation for oxygen deprivation; trapped in footlocker by older brother.

05/07/68: Bellaire Medical Center — 10 stitches to left foot; caught in bicycle spokes.

07/21/72: Kerr County Hospital — bone fracture (left wrist), internal contusions (kidney), 14 stitches (cranial); fall off cliff, summer camp.

09/15/72: Memorial City Hospital — 183 stitches to right thigh; deep laceration from playing in woodpile.

04/04/77: Memorial City Hospital — multiple contusions/abrasions; auto accident.

09/23/79: Denver General Hospital — pump stomach; alcohol poisoning.

06/15/81: Bay Medical — 11-stitches to forehead; impact from water-ski.

05/25/83: Summit County Medical — knee-brace; rock climbing accident.

11/24/87: Ben Taub — blunt-force trauma/contusions/abrasions; assault by girlfriend.

07/04/90: Bay Medical — 1st & 2nd degree burns on face & right forearm; barbecue mishap.

02/08/93: Los Cabos Infirmary — hernia/strained hamstring; post-nuptial exertion.

09/10/96: Women’s Hospital — 4-stitches to bottom lip; spouse in labor.

06/06/01: Bellaire Medical Center — concussion; T-ball incident.

Briefly describe current complaint:________________________________________________

 


 

Copyright 2002 by David Falloure