------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v11.1) 01/10/2011 09:18 Name: MHVVETERAN, ONE A Date of Birth: 03/01/1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 01/10/2011 09:18 AM CST User Request Type: Download all of my available data from My HealtheVet File Name: mhv_MHVVETERAN_20110110.txt --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 08/19/2010 Authentication Facility ID: 979 Authentication Facility Name: SLC10 TEST LAB VA Treating Facility Type ---------------------------- ----------- AUSTIN PSIM OTHER DAYT29 M&ROC ----------------------------- DEMOGRAPHICS ---------------------------- Source: Self-Entered First Name: ONE Middle Initial: A Last Name: MHVVETERAN Suffix: Alias: MHVVET Relationship to VA: Patient, Veteran, Employee Gender: Male Blood Type: AB+ Organ Donor: Yes Date of Birth: 03/01/1948 Marital Status: Married Current Occupation: Truck Driver Mailing Address: 123 Anywhere Road Mailing Address2: Apartment 123 Mailing City: Anywhere Mailing State: DC Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 00001 Alternate Address: Alternate Address2: Alternate City: Alternate State: Alternate Country: Alternate Province: Alternate Zip/Postal Code: Home Phone Number: 000-010-0101 Work Phone Number: 000-020-0202 Pager Number: 000-030-0303 Cell Phone Number: 000-040-0404 FAX Number: 000-050-0505 Email Address: mhvveteran@emailaddress.com Preferred Method of Contact: Email EMERGENCY CONTACTS Contact First Name: Two Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-010-0101 Work Phone Number: 000-060-0606 Extension: Cell Phone Number: 000-070-0707 Address Line 1: 123 Anywhere Road Address Line 2: Apartment 123 City: Anywhere State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: twomhvveteran@domain.com Contact First Name: Three Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-010-0101 Work Phone Number: 000-080-0808 Extension: Cell Phone Number: 000-090-0909 Address Line 1: 123 Anywhere Road Address Line 2: Apartment 123 City: Anywhere State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: threemhvveteran@domain.com ------------------------- HEALTH CARE PROVIDERS ------------------------- Source: Self-Entered Provider Name: John Doe Type of Provider: Primary Other Clinician Information: Phone Number: 000-000-0000 Ext: 1234 Email: provider@institution.org Comments: Dr. Doe can be reached on the weekend if needed by leaving a message with the clinic. Provider Name: Jane Smith Type of Provider: Specialist Other Clinician Information: Seen as needed Phone Number: 000-000-0001 Ext: 1234 Email: specialist@institution.org Comments: Dr. Smith should be notified of any changes in my medical condition. Requires a referral from my health insurance company. ------------------------- TREATMENT FACILITIES -------------------------- Source: Self-Entered Facility Name: Anywhere VA Medical Center Facility Type: VA VA Home Facility: Yes Phone Number: 000-000-0001 Ext: 1234 Mailing Address: 123 VA Drive Mailing Address2: Suite 4 Mailing City: Anywhere Mailing State: DC Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 00001 Comments: Contact clinic when calling to make my appointments. Facility Name: Health Care Inc. Facility Type: Non-VA VA Home Facility: No Phone Number: 000-000-0002 Ext: 5678 Mailing Address: 123 Anywhere Road Mailing Address2: B-Wing Mailing City: Anywhere Mailing State: DC Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 00001 Comments: Reminder to bring My HealtheVet printouts for all visits --------------------------- HEALTH INSURANCE ---------------------------- Source: Self-Entered Health Insurance Company: My Health Insurance Company Primary Insurance Provider: Yes ID Number: 0001234 Group Number: 0000000 Insured: One Mhvveteran Start Date: 01/01/2000 Stop Date: Pre-Approval Phone Number: 000-000-0003 Health Insurance Company Phone Number: 000-000-0004 Comments: Need to get pre-authorization for special services. Health Insurance Company: My Other Health Insurance Company Primary Insurance Provider: No ID Number: 000567891010 Group Number: ABC123456789 Insured: One Mhvveteran Start Date: 01/01/2009 Stop Date: Pre-Approval Phone Number: 000-000-0005 Health Insurance Company Phone Number: 000-000-0005 Comments: Coverage only for vision and dental. ---------------------------- VA WELLNESS REMINDERS ------------------------- Source: VA Wellness Reminder Due Date Last Completed Location ---------------------------------------------------------------------------- Body Mass >25 Alert DUE NOW UNKNOWN DAYT29 Colon Cancer Screening 8/13/2011 8/13/2010 DAYT29 Influenza Vaccination 8/13/2011 8/13/2010 DAYT29 Elevated Cholesterol Alert 8/13/2012 8/13/2010 DAYT29 Eye Exam For Diabetes 8/13/2011 8/13/2010 DAYT29 Foot Exam For Diabetes 8/13/2011 8/13/2010 DAYT29 HbA1c for Diabetes 8/13/2011 8/13/2010 DAYT29 Elevated Blood Pressure Alert DUE NOW 8/01/2009 DAYT29 Lipid Measurement (Cholesterol) 8/01/2011 8/01/2009 DAYT29 Pneumonia Vaccine DUE NOW UNKNOWN DAYT29 Learn more about these Wellness Reminders by visiting My HealtheVet. Please contact your health care team with any questions about your VA Wellness Reminders. --------------------------- VA APPOINTMENTS ----------------------------- Source: VA VA Past Appointments are limited to two years from the date of your download request. FUTURE APPOINTMENTS: -------------------- Date/Time: 10/13/2011 04:00 PM Location: DAYT29 TEST LAB Status: FUTURE Clinic: C&P CHRISTIE Phone Number: 3929 Type: Compensation and Pension Appointment Date/Time: 09/07/2011 11:00 AM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Date/Time: 07/27/2011 02:00 PM Location: DAYT29 TEST LAB Status: FUTURE Clinic: DIABETIC-BURKE Phone Number: 800-123-1234 Note: This appointment has pre-appointment activity scheduled: Lab: 07/27/2011 10:00 AM Date/Time: 06/15/2011 01:00 PM Location: DAYT29 TEST LAB Status: FUTURE Clinic: DIABETIC-BURKE Phone Number: 800-123-1234 Note: This appointment has pre-appointment activity scheduled: Lab: 06/15/2011 08:00 AM EKG: 06/15/2011 10:30 AM X-Ray: 06/15/2011 09:00 AM Date/Time: 05/03/2011 11:00 AM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Note: This appointment has pre-appointment activity scheduled: X-Ray: 05/03/2011 08:00 AM Date/Time: 03/15/2011 10:00 AM Location: MIDDLETOWN Status: CANCELLED Clinic: MD/DENTAL FOSTER Phone Number: 2449 Note: This appointment has pre-appointment activity scheduled: Lab: 03/15/2011 09:30 AM PAST APPOINTMENTS: -------------------- Date/Time: 01/06/2011 10:00 AM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: PRP JOHNSON,C (GRP) Phone Number: 2188 Note: This appointment has pre-appointment activity scheduled: Lab: 01/06/2011 09:00 AM EKG: 01/06/2011 09:30 AM Date/Time: 01/03/2011 01:00 PM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: PRP JOHNSON,C (GRP) Phone Number: 2188 Date/Time: 12/29/2010 10:00 AM Location: MIDDLETOWN Status: NOT APPLICABLE Clinic: MD/PODIATRY NGUYEN (Follow-Up) Phone Number: 5416 Date/Time: 08/30/2010 02:00 PM Location: DAYT29 TEST LAB Status: APPOINTMENT KEPT Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Date/Time: 07/14/2010 09:00 AM Location: MIDDLETOWN Status: NOT APPLICABLE Clinic: MD/PODIATRY NGUYEN (Follow-Up) Phone Number: 5416 -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA VA Medication History includes up to two years of medication history unless you select a different date range in your download request. Medication: AMLODIPINE BESYLATE 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH TAKE ONE-HALF TABLET FOR 1 DAY --AVOID GRAPEFRUIT JUICE-- Status: Active Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 08/13/2010 Quantity: 45 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718953 Medication: FREESTYLE (GLUCOSE) TEST STRIP Instructions: USE 1 STRIP FOR TESTING AS DIRECTED Status: Active Refills Remaining: 2 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 200 Days Supply: 50 Pharmacy: DAYTON Prescription Number: 2718959 Medication: IBUPROFEN 600MG TAB Instructions: TAKE ONE TABLET BY MOUTH FOUR TIMES A DAY WITH FOOD AS NEEDED Status: Active Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 240 Days Supply: 60 Pharmacy: DAYTON Prescription Number: 2718960 Medication: INSULIN,GLARGINE,HUMAN 100 UNT/ML INJ Instructions: INJECT 10 ML VIAL UNDER THE SKIN AS DIRECTED FOR 28 DAYS INJECT 25 UNITS UNDER THE SKIN AT BEDTIME DO NOT MIX WITH OTHER INSULINS/DISCARD OPEN VIALS AFTER 28 DAYS Status: Active Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 30 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718956 Medication: LISINOPRIL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH DAILY Status: Active Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 90 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718954 Medication: METFORMIN HCL 1000MG TAB Instructions: TAKE ONE TABLET BY MOUTH TWICE A DAY WITH MEALS FOR DIABETES Status: Active Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 180 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718955 Medication: SIMVASTATIN 20MG TAB Instructions: TAKE ONE TABLET BY MOUTH AT BEDTIME FOR CHOLESTEROL - CALL YOUR PROVIDER IF YOU HAVE UNEXPLAINED MUSCLE PAIN, TENDERNESS OR WEAKNESS. Status: Active Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 90 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718957 Medication: TERAZOSIN HCL 2MG CAP Instructions: TAKE THREE CAPSULES BY MOUTH AT BEDTIME. Status: Active Refills Remaining: 2 Last Filled On: 08/20/2010 Initially Ordered On: 07/01/2010 Quantity: 270 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718958 Medication: INSULIN NPH HUMAN 100 U/ML INJ NOVOLIN N Instructions: INJECT 16 UNITS UNDER THE SKIN EVERY MORNING AND INJECT 18 UNITS AT BEDTIME Status: Discontinued Refills Remaining: 3 Last Filled On: 08/20/2010 Initially Ordered On: 05/24/2010 Quantity: 30 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718962 Medication: COLON ELECTROLYTE LAVAGE PWD FOR SOLN Instructions: DISSOLVE ONE BOTTLE BY MOUTH AS DIRECTED. START DRINKING AT 2 EVENING ON DAY PRIOR TO EXAM, DRINK ONE LARGE GLASS EVERY TEN MIN. Status: Expired Refills Remaining: 0 Last Filled On: 07/01/2010 Initially Ordered On: 07/01/2010 Quantity: 1 Days Supply: 2 Pharmacy: DAYTON Prescription Number: 2718961 Medication: TABLET CUTTER Instructions: USE AS DIRECTED TO SPLIT TABLETS Status: Expired Refills Remaining: 0 Last Filled On: 05/24/2010 Initially Ordered On: 05/24/2010 Quantity: 1 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718963 Medication: LISINOPRIL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH A FOR 30 DAYS Status: Submitted Refills Remaining: 2 Last Filled On: 10/14/2009 Initially Ordered On: 10/14/2009 Quantity: 30 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718944 Medication: SODIUM CHLORIDE 0.65% SOLN NASAL SPRAY Instructions: SPRAY 2 SPRAYS IN NOSTRIL Status: Refill in Process Refills Remaining: 3 Last Filled On: 10/01/2009 Initially Ordered On: 09/11/2009 Quantity: 10 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718884 Medication: LISINOPRIL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH Status: Discontinued Refills Remaining: 3 Last Filled On: 09/23/2009 Initially Ordered On: 09/23/2009 Quantity: 90 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718922 Medication: PSEUDOEPHEDRINE 60MG TAB Instructions: TAKE ONE TABLET BY MOUTH Status: Expired Refills Remaining: 3 Last Filled On: 09/23/2009 Initially Ordered On: 09/23/2009 Quantity: 30 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718912 Medication: DEXAMETHASONE 4MG TAB Instructions: TAKE TWO TABLETS BY MOUTH --TAKE WITH FOOD-- Status: Expired Refills Remaining: 2 Last Filled On: 09/23/2009 Initially Ordered On: 09/23/2009 Quantity: 96 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718913 Medication: NAPROXEN 500MG TAB Instructions: TAKE ONE TABLET BY MOUTH FOR 30 DAYS --TAKE WITH FOOD IF GI UPSET Status: Expired Refills Remaining: 2 Last Filled On: 09/12/2009 Initially Ordered On: 09/12/2009 Quantity: 60 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718886 Medication: ASPIRIN 325MG BUFFERED TAB Instructions: TAKE ONE TABLET BY MOUTH FOR 45 DAYS --AVOID ANTACIDS-- Status: Expired Refills Remaining: 3 Last Filled On: 09/11/2009 Initially Ordered On: 09/11/2009 Quantity: 1 Days Supply: 45 Pharmacy: DAYTON Prescription Number: 2718885 Medication: FLUTICAS 250/SALMETEROL 50 INHL DISK 28 Instructions: USE 1 INHALATION Status: Expired Refills Remaining: 5 Last Filled On: 09/11/2009 Initially Ordered On: 09/11/2009 Quantity: 1 Days Supply: 60 Pharmacy: DAYTON Prescription Number: 2718883 Medication: BACITRACIN 500 UNIT/GM OINT 30GM Instructions: APPLY SMALL AMOUNT TO AFFECTED AREA 2-3 TIMES A DAY FOR 30 DAYS Status: Expired Refills Remaining: 1 Last Filled On: 09/11/2009 Initially Ordered On: 09/11/2009 Quantity: 10 Days Supply: 45 Pharmacy: DAYTON Prescription Number: 2718880 Medication: ESOMEPRAZOLE MAGNESIUM 40MG SA CAP Instructions: TAKE ONE CAPSULE BY MOUTH Status: Expired Refills Remaining: 2 Last Filled On: 09/11/2009 Initially Ordered On: 09/11/2009 Quantity: 1 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718881 Medication: ATORVASTATIN CALCIUM 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH --AVOID GRAPEFRUIT Status: Expired Refills Remaining: 3 Last Filled On: 09/11/2009 Initially Ordered On: 09/11/2009 Quantity: 90 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718882 Medication: FAMOTIDINE 20MG TAB Instructions: TAKE ONE TABLET BY MOUTH FIVE TIMES DAILY --MAY TAKE WITH FOOD/AVOID ANTACIDS Status: Expired Refills Remaining: 3 Last Filled On: 09/11/2009 Initially Ordered On: 09/11/2009 Quantity: 180 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718879 -------------------------- MEDICATIONS AND SUPPLEMENTS ---------------------- Source: Self-Entered Category: RX Medication Drug Name: Aspirin EC Prescription Number: 010101B Strength: 81mg Dose: 1 tab Frequency: daily Start Date: 06/15/2005 Stop Date: Pharmacy Name: My Local Drugstore Pharmacy Phone: 000-010-0000 Reason for taking: Daily regimen for heart health Comments: Category: OTC Drug Name: Cough Medicine Prescription Number: Strength: 1000mg Dose: 2 TBS Frequency: morning and night Start Date: 02/01/2010 Stop Date: 02/21/2010 Pharmacy Name: My Local Drugstore Pharmacy Phone: 000-010-0000 Reason for taking: Cough was keeping me up at night Comments: Cleared up after a few weeks Category: Herbal Drug Name: Ginkgo biloba Prescription Number: Strength: Dose: 2 capsules Frequency: once a day Start Date: 03/08/2008 Stop Date: Pharmacy Name: My Local Drugstore Pharmacy Phone: 000-010-0000 Reason for taking: Wife suggested to improve concentration Comments: Take in the morning with breakfast Category: Supplement Drug Name: Multi-vitamin Prescription Number: Strength: 100% RDA Dose: 1 tablet daily Frequency: morning Start Date: 03/18/2010 Stop Date: Pharmacy Name: My Local Drugstore Pharmacy Phone: 000-010-0000 Reason for taking: To stay healthy Comments: Feeling more energetic since I started taking vitamin -------------------------- ALLERGIES/ADVERSE REACTIONS --------------------- Source: Self-Entered Allergy Name: Peanuts Date: 08/01/1980 Severity: Moderate Diagnosed: Yes Reaction: Hives Comments: Avoid peanuts and peanut based foods. Foods cooked with peanut oil also cause the reaction Allergy Name: Pollen Date: 03/18/2010 Severity: Mild Diagnosed: Yes Reaction: Watery eyes, itchy nose Comments: Took an over the counter antihistamine ------------------------------ MEDICAL EVENTS ------------------------------- Source: Self-Entered Medical Event: Colonoscopy Start Date: 03/18/2000 Stop Date: 03/18/2000 Response: Colonoscopy when well Comments: Polyps were removed. Doctor said these were benign Medical Event: Broken right arm Start Date: 01/04/2010 Stop Date: 02/17/2010 Response: Placed in cast from my hand to my elbow Comments: Went to community hospital emergency room since I was on vacation. Followed up with my VA doctor when I returned home. ----------------------------- IMMUNIZATIONS --------------------------------- Source: Self-Entered Immunization: Measles + Rubella (German Measles) Other: none Method: Injection Date Received: 03/01/1950 Reactions: --------------------------------- Pain Comments: Received as a child Immunization: Flu Other: H1N1 Method: Inhalant Date Received: 09/01/2009 Reactions: --------------------------------- Comments: Had no reaction Immunization: Tetanus Other: none Method: Injection Date Received: 07/18/2010 Reactions: --------------------------------- Pain Comments: stepped on a rusty nail ----------------------------- LABS AND TESTS -------------------------------- Source: Self-Entered Test Name: Blood Test Date: 06/06/2010 Location performed: Community Center Provider: Red Cross Blood Drive Results: Was not able to donate blood because iron was low Comments: Will ask doctor at next visit Test Name: Colonoscopy Date: 07/01/2010 Location performed: VAMC Provider: Provider One Results: No new polyps Comments: Keep high fiber diet ----------------------------- VITALS AND READINGS --------------------------- Source: Self-Entered ================================================================================ Measurement Type: Blood pressure Date: 08/02/2010 Time: 17:20 Systolic: 130 Diastolic: 76 Comments: BP taken lying down ================================================================================ Measurement Type: Blood pressure Date: 08/02/2010 Time: 17:30 Systolic: 132 Diastolic: 76 Comments: BP taken standing. BP continues at goal. Doctor says to continue BP medications as directed ================================================================================ Measurement Type: Heart rate Date: 06/02/2010 Time: 17:20 Heart Rate: 160 Comments: Started taking Beta-Blockers after visit with physician ================================================================================ Measurement Type: Body weight Date: 04/02/2010 Time: 17:20 Body Weight: 246 Measure: Pounds Comments: Talk to provider about weight management program at next visit ================================================================================ Measurement Type: Body weight Date: 05/02/2010 Time: 17:20 Body Weight: 244 Measure: Pounds Comments: Lost a few pounds and feel better. Walking daily ================================================================================ Measurement Type: Body weight Date: 06/02/2010 Time: 17:20 Body Weight: 242 Measure: Pounds Comments: still walking when I have time off from work ================================================================================ Measurement Type: Body temperature Date: 03/02/2010 Time: 17:20 Body temperature: 98.5 Measure: Fahrenheit Method: Mouth Comments: I wasn't feeling well but temperature is normal ================================================================================ Measurement Type: Pain Date: 01/01/2010 Time: 17:20 Pain Level: 7 Comments: Lower back pain - took 1 Ibuprofen with food for pain ================================================================================ Measurement Type: Blood sugar Date: 01/02/2010 Time: 17:20 Method: Sterile Lancet Blood sugar count: 166 Comments: BS taken before meal ================================================================================ Measurement Type: Cholesterol Date: 08/15/2010 Time: Total cholesterol: 142 HDL: 45 LDL: Comments: Lab result from community health fair. -------------------------- FAMILY HEALTH HISTORY ---------------------------- Source: Self-Entered Relationship: Self First Name: ONE Last Name: MHVVETERAN Living or Deceased: Living Health Issues: ----------------------------- Back Pain Insomnia >1 beer/wine a day Hearing Loss Pneumonia Smoking >1 pack/day Allergies Chicken Pox Current Smoker Diabetics Type 2 Overweight High Blood Pressure Depression High Blood Cholesterol Stomach/Bowel Other Smoking >20 Years Other Health Issues: ----------------------------- trouble sleeping Comments: I sometimes have trouble sleeping when stress is high at work Relationship: Mother First Name: Four Last Name: MHVVeteranMother Living or Deceased: Deceased Health Issues: ----------------------------- Cancer Other Diabetics Type 2 Overweight Joint Pain Stroke Other Health Issues: ----------------------------- Chronic joint pain Comments: Mother died of cancer at age 40 --------------------------- MILITARY HEALTH HISTORY ------------------------- Source: Self-Entered Event Title: Overseas Deployment Event Date: 04/07/2002 Service Branch: Army Rank: Captain Exposures: Yes Location of Service: Overseas Onboard Ship: No Military Occupational Specialty: Infantry Assignment: 1st Recon Exposures: Iraq: Exposed to burning chemicals Military Service Description: Unit was in charge of security -------------- END MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------