------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v11.2) 03/21/2011 07:38 This summary is a copy of information from your My HealtheVet Personal Health Record. Your summary contains information that you entered and may also include a copy of some of the information in your VA medical record as it becomes available in My HealtheVet. Please let your health care team know if you have questions about your health information. Name: MHVVETERAN, ONE A Date of Birth: 03/01/1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 03/21/2011 07:38 AM CST User Request Type: Download only my selected data from My HealtheVet File Name: mhv_MHVVETERAN_20110321.txt Data Types Selected: My HealtheVet Account Summary Demographics VA Appointments (Future) VA Appointments (Limited to past 2 years) --------------------- 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 --------------------------- VA APPOINTMENTS ----------------------------- Source: VA Last Updated: 03/18/2011 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 PAST APPOINTMENTS: -------------------- 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 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 -------------- END MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------