Structured clinical history — signed, auditable, and ready for any covering clinician.
No known allergies
Confirmed by attending — signed on record.
Folic acid · 5 mg
Once daily
Ferrous sulphate · 200 mg
Twice daily
Tobacco
Never
Alcohol · AUDIT-C
Never
Physical activity
4 × 30 min
Occupation
Accountant
Housing
Stable
Substance use
Denies.
Attested by Dr. Neema Lyimo.
Surrogate decision-maker: David Ouma (Husband)
Advance directive on file
POLST / MOLST attachment: not uploaded. Upload a scanned document or use the in-app attestation workflow to formalise.