Structured clinical history — signed, auditable, and ready for any covering clinician.
Dust mites
Rhinitis, Wheeze
moderateEnvironmental—
Fluticasone + Salmeterol (Seretide) · 125/25 mcg
Two puffs BD
Salbutamol MDI · 100 mcg
PRN for wheeze
Tobacco
Never
Alcohol · AUDIT-C
Never
Physical activity
5 × 60 min
Occupation
Student (Grade 3)
Housing
Stable
Substance use
N/A — paediatric.
Attested by Dr. Fatuma Said.
Surrogate decision-maker: Rehema Mushi (Mother)
Advance directive on file
POLST / MOLST attachment: not uploaded. Upload a scanned document or use the in-app attestation workflow to formalise.