Structured clinical history — signed, auditable, and ready for any covering clinician.
NSAIDs
GI bleed history
severeDrug—
Omeprazole · 20 mg
Once daily before breakfast
Sertraline · 50 mg
Once daily
Inguinal hernia repair (L)
12 Aug 2015
—
—
Tobacco
Current some day
Alcohol · AUDIT-C
Occasional
Physical activity
2 × 20 min
Occupation
Bank manager
Housing
Stable
Substance use
Denies.
Attested by Dr. Majani Edward.
Surrogate decision-maker: Halima Bakari (Wife)
Advance directive on file
POLST / MOLST attachment: not uploaded. Upload a scanned document or use the in-app attestation workflow to formalise.