------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v11.3.1) 11 Jul 2011 @ 0557 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: MHVTESTVETERAN, ONE Date of Birth: 01 Mar 1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 11 Jul 2011 @ 0557 User Request Type: Download only my selected data from My HealtheVet File Name: mhv_MHVTESTVETERAN_20110711.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: 18 May 2011 Authentication Facility ID: 648 Authentication Facility Name: PORTLAND, OREGON VA MEDICAL CENTER VA Treating Facility Type ---------------------------- ----------- AUSTIN MHV OTHER AUSTIN PSIM OTHER PORTLAND, OREGON VA MEDICAL CENTER VAMC ----------------------------- DEMOGRAPHICS ---------------------------- Source: Self-Entered First Name: ONE Middle Initial: Last Name: MHVTESTVETERAN Suffix: Alias: MHVVET Relationship to VA: Patient, Veteran Gender: Male Blood Type: AB+ Organ Donor: Yes Date of Birth: 01 Mar 1948 Marital Status: Married Current Occupation: Truck Driver Mailing Address: 123 Anywhere Road Mailing Address2: Apt. 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: 000-020-0202 Work Phone Number: 000-040-0404 Pager Number: Cell Phone Number: 000-030-0303 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: 000-010-0001 Work Phone Number: Extension: Cell Phone Number: Address Line 1: 123 Anywhere Road Address Line 2: City: Anywhere State: DC Country: United States Province: Zip/Post Code: 000001 Email Address: 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: City: State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: --------------------------- VA APPOINTMENTS ----------------------------- Source: VA Last Updated: 11 Jul 2011 @ 0523 VA Past Appointments are limited to two years from the date of your download request. FUTURE APPOINTMENTS: -------------------- Date/Time: 30 May 2012 @ 1600 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Date/Time: 07 May 2012 @ 1100 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Date/Time: 27 Jan 2012 @ 1400 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: Lab: 27 Jan 2012 @ 1000 Date/Time: 15 Dec 2011 @ 1300 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: Lab: 15 Dec 2011 @ 0800 EKG: 15 Dec 2011 @ 1030 X-Ray: 15 Dec 2011 @ 0900 Date/Time: 03 Nov 2011 @ 1100 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: X-Ray: 03 Nov 2011 @ 0800 PAST APPOINTMENTS: -------------------- Date/Time: 15 Mar 2011 @ 1000 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: Lab: 15 Mar 2011 @ 0930 Date/Time: 06 Mar 2011 @ 1000 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: Lab: 06 Mar 2011 @ 0900 EKG: 06 Mar 2011 @ 0930 Date/Time: 03 Jan 2011 @ 1300 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Date/Time: 30 Aug 2010 @ 1400 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 -------------- END MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------