------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v11.2) 03/21/2011 07:49 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 07:49 AM CST User Request Type: Download only my selected data from My HealtheVet File Name: mhv_MHVVETERAN_20110321.txt Date Range Selected: 03/21/2010 to 03/21/2011 Data Types Selected: My HealtheVet Account Summary Demographics Health Care Providers Treatment Facilities Health Insurance VA Wellness Reminders VA Appointments (Future) VA Appointments (Limited to past 2 years) VA Medication History Medications and Supplements VA Allergies Allergies/Adverse Reactions Medical Events Immunizations Labs and Tests Vitals and Readings Family Health History Military Health History --------------------- 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 Last Updated: 03/18/2011 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 Last Updated: 03/18/2011 VA Past Appointments are limited to two years from the date of your download request. 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 -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA Last Updated: 03/17/2011 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: 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: FREESTYLE (GLUCOSE) TEST STRIP Instructions: USE 1 STRIP FOR TESTING AS DIRECTED Status: Submitted 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: COLON ELECTROLYTE LAVAGE PWD FOR SOLN Instructions: TAKE 1 CONTAINER MOUTH AS DIRECTED FOR 1 DAY DISSOLVE 1 BOTTLE 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 MOUTH AS DIRECTED FOR 3 DAYS USE AS DIRECTED TO SPLIT 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 ---------------------------- VA ALLERGIES ------------------------- Source: VA Last Updated: 03/18/2011 Allergy Name: METHOCARBAMOL Location: DAYT29 Date Entered: 03/09/2011 Reaction: CONFUSION, DROWSINESS Allergy Type: DRUG VA Drug Class: SKELETAL MUSCLE RELAXANTS Observed/Historical: OBSERVED Comments: Drowsiness and hallucinations while on methocarbamol plus carbamazepine and other sedatives Allergy Name: TERAZOSIN Location: DAYT29 Date Entered: 03/09/2011 Reaction: DIZZINESS Allergy Type: DRUG VA Drug Class: ALPHA BLOCKERS/RELATED Observed/Historical: HISTORICAL Comments: Lightheadedness on 10mg qhs Terazoin resolved upon stopping Terazoin. Allergy Name: BACTRIM Location: DAYT29 Date Entered: 03/09/2011 Reaction: Allergy Type: DRUG VA Drug Class: SULFONAMIDE/RELATED ANTIMICROBIALS Observed/Historical: HISTORICAL Comments: Causes Swelling of the Extremeties Allergy Name: TRAMADOL Location: DAYT29 Date Entered: 03/09/2011 Reaction: URINARY RETENTION Allergy Type: DRUG VA Drug Class: NON-OPIOID ANALGESICS Observed/Historical: HISTORICAL Comments: gradually worsening difficulty emptying bladder -- might try tramadol again cautiously because pt. reported pain relief Allergy Name: TRIMETHOPRIM Location: DAYT29 Date Entered: 03/09/2011 Reaction: Allergy Type: DRUG VA Drug Class: ANTI-INFECTIVES,OTHER Observed/Historical: HISTORICAL Comments: The reaction to this allergy was MILD (NO SQUELAE) Please contact your health care team with any questions about your VA Allergy information. ----------------------------- IMMUNIZATIONS --------------------------------- Source: Self-Entered 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: 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 ------------