------------------ MY HEALTHEVET PERSONAL INFORMATION REPORT ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v12) 02 Dec 2011 @ 1023 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. For some Veterans, information from the Department of Defense (DoD) is available. You will see this in VA Blue Button as DoD Military Service Information. Name: MHVVETERAN, ONE A Date of Birth: 01 Mar 1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 02 Dec 2011 @ 1023 User Request Type: Download all of my available data from My HealtheVet File Name: mhv_MHVVETERAN_20111202.txt 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 VA Laboratory Results Labs and Tests Vitals and Readings Family Health History Military Health History DoD Military Service Information --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 19 Aug 2010 Authentication Facility ID: 979 Authentication Facility Name: SLC10 TEST LAB VA Treating Facility Type ---------------------------- ----------- DAYT29 M&ROC AUSTIN HDR INT OTHER AUSTIN PSIM OTHER ----------------------------- 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: 01 Mar 1948 Marital Status: Married Current Occupation: Truck Driver Mailing or Destination Address: 123 Anywhere Road Mailing or Destination Address2: Apartment 123 Mailing or Destination City: Anywhere Mailing or Destination State: DC Mailing or Destination Country: United States Mailing or Destination Province: Mailing or Destination Zip/Postal Code: 00001 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 Jan 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 Jan 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: 02 Dec 2011 @ 0706 Wellness Reminder Due Date Last Completed Location ---------------------------------------------------------------------------- Colon Cancer Screening DUE NOW UNKNOWN DAYT29 Influenza 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: 02 Dec 2011 @ 0706 VA Past Appointments are limited to two years from the date of your download request. FUTURE APPOINTMENTS: -------------------- Date/Time: 13 Oct 2012 @ 1100 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: C&P CHRISTIE Phone Number: 3929 Type: Compensation and Pension Appointment PAST APPOINTMENTS: -------------------- Date/Time: 13 Oct 2011 @ 1600 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: C&P CHRISTIE Phone Number: 3929 Type: Compensation and Pension Appointment Date/Time: 07 Sep 2011 @ 1100 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Date/Time: 27 Jul 2011 @ 1400 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: DIABETIC-BURKE Phone Number: 800-123-1234 Note: This appointment has pre-appointment activity scheduled: Lab: 27 Jul 2011 @ 1000 Date/Time: 15 Jun 2011 @ 1300 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: DIABETIC-BURKE Phone Number: 800-123-1234 Note: This appointment has pre-appointment activity scheduled: Lab: 15 Jun 2011 @ 0800 EKG: 15 Jun 2011 @ 1030 X-Ray: 15 Jun 2011 @ 0900 Date/Time: 03 May 2011 @ 1100 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Note: This appointment has pre-appointment activity scheduled: X-Ray: 03 May 2011 @ 0800 Date/Time: 15 Mar 2011 @ 1000 Location: MIDDLETOWN Status: CANCELLED Clinic: MD/DENTAL FOSTER Phone Number: 2449 Note: This appointment has pre-appointment activity scheduled: Lab: 15 Mar 2011 @ 0930 Date/Time: 06 Jan 2011 @ 1000 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: PRP JOHNSON,C (GRP) Phone Number: 2188 Note: This appointment has pre-appointment activity scheduled: Lab: 06 Jan 2011 @ 0900 EKG: 06 Jan 2011 @ 0930 Date/Time: 03 Jan 2011 @ 1300 Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: PRP JOHNSON,C (GRP) Phone Number: 2188 Date/Time: 29 Dec 2010 @ 1000 Location: MIDDLETOWN Status: NOT APPLICABLE Clinic: MD/PODIATRY NGUYEN (Follow-Up) Phone Number: 5416 Date/Time: 30 Aug 2010 @ 1400 Location: DAYT29 TEST LAB Status: APPOINTMENT KEPT Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Date/Time: 14 Jul 2010 @ 0900 Location: MIDDLETOWN Status: NOT APPLICABLE Clinic: MD/PODIATRY NGUYEN (Follow-Up) Phone Number: 5416 -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA Last Updated: 11 Apr 2011 @ 1737 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: 20 Aug 2010 Initially Ordered On: 13 Aug 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: 20 Aug 2010 Initially Ordered On: 01 Jul 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: 20 Aug 2010 Initially Ordered On: 01 Jul 2010 Quantity: 30 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718956 Medication: TERAZOSIN HCL 2MG CAP Instructions: TAKE THREE CAPSULES BY MOUTH AT BEDTIME. Status: Active Refills Remaining: 2 Last Filled On: 20 Aug 2010 Initially Ordered On: 01 Jul 2010 Quantity: 270 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718958 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: 20 Aug 2010 Initially Ordered On: 01 Jul 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: 20 Aug 2010 Initially Ordered On: 01 Jul 2010 Quantity: 90 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718957 Medication: LISINOPRIL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH DAILY Status: Active Refills Remaining: 3 Last Filled On: 20 Aug 2010 Initially Ordered On: 01 Jul 2010 Quantity: 90 Days Supply: 90 Pharmacy: DAYTON Prescription Number: 2718954 Medication: INSULIN NPH HUMAN 100 U/ML INJ NOVOLIN N Instructions: INJECT 16 UNITS UNDER THE SKIN EVERY MORNING AND INJECT 18 UNITS AT BEDTIMEnull Status: Discontinued Refills Remaining: 3 Last Filled On: 20 Aug 2010 Initially Ordered On: 24 May 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: 20 Aug 2010 Initially Ordered On: 01 Jul 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 BY Status: Expired Refills Remaining: 0 Last Filled On: 01 Jul 2010 Initially Ordered On: 01 Jul 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: 24 May 2010 Initially Ordered On: 24 May 2010 Quantity: 1 Days Supply: 30 Pharmacy: DAYTON Prescription Number: 2718963 -------------------------- 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: 15 Jun 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: 01 Feb 2010 Stop Date: 21 Feb 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: 08 Mar 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: 18 Mar 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 ---------------------------- VA ALLERGIES ------------------------- Source: VA Last Updated: 01 Dec 2011 @ 0851 Allergy Name: TRIMETHOPRIM Location: DAYT29 Date Entered: 09 Mar 2011 Reaction: Allergy Type: DRUG VA Drug Class: ANTI-INFECTIVES,OTHER Observed/Historical: HISTORICAL Comments: The reaction to this allergy was MILD (NO SQUELAE) Allergy Name: TRAMADOL Location: DAYT29 Date Entered: 09 Mar 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 releif Allergy Name: BACTRIM Location: DAYT29 Date Entered: 09 Mar 2011 Reaction: Allergy Type: DRUG VA Drug Class: SULFONAMIDE/RELATED ANTIMICROBIALS Observed/Historical: HISTORICAL Comments: Causes Swelling of the Extremeties Allergy Name: TERAZOSIN Location: DAYT29 Date Entered: 09 Mar 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: METHOCARBAMOL Location: DAYT29 Date Entered: 09 Mar 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 Please contact your health care team with any questions about your VA Allergy information. -------------------------- ALLERGIES/ADVERSE REACTIONS --------------------- Source: Self-Entered Allergy Name: Peanuts Date: 01 Aug 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: 18 Mar 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: 18 Mar 2000 Stop Date: 18 Mar 2000 Response: Colonoscopy when well Comments: Polyps were removed. Doctor said these were benign Medical Event: Broken right arm Start Date: 04 Jan 2010 Stop Date: 17 Feb 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: 01 Mar 1950 Reactions: --------------------------------- Pain Comments: Received as a child Immunization: Flu Other: H1N1 Method: Inhalant Date Received: 01 Sep 2009 Reactions: --------------------------------- Comments: Had no reaction Immunization: Tetanus Other: none Method: Injection Date Received: 18 Jul 2010 Reactions: --------------------------------- Pain Comments: stepped on a rusty nail -------------------------- VA LABORATORY RESULTS ---------------------------- Source: VA Last Updated: 01 Dec 2011 @ 0851 Sorted By: Date Specimen Collected (Descending) VA Laboratory Results includes up to two years of history unless you select a different date range in your download request. ============================================================================= Lab Test: Prothrombin Time+PTT Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Plasma Date/Time Collected: 27 Jun 2011 ----------------------------------------------------------------------------- Test Name: COAGULATION SURFACE INDUCED.FACTOR SUBSTITUTION~IMMEDIATELY AFTER ADDITION OF NORMAL PLASMA Result: 13.2 Low Units: SECONDS Reference Range: (59.0-104.0) Interpretation: Current normal range = 20.3 -35.8 seconds. Normal range prior to 7/5/02 was 25.3 - 40.4 sec. Normal range prior to 2/26/98 was 26.1 - 43.0 sec. Therapeutic range prior to 7/5/02 was 67.0 - 118.0 sec. Therapeutic range prior to 2/26/98 was 72.0 - 126.0 sec. Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: COAGULATION TISSUE FACTOR INDUCED Result: 9.9 Low Units: SECONDS Reference Range: (23.0-33.0) Interpretation: Current normal range = 10.8 - 13.7 seconds. Normal range prior to 7/5/02 was 10.7 - 14.1 seconds. INR should be used for therapeutic decisions. Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: COAGULATION TISSUE FACTOR INDUCED.INR Result: .7 Units: Reference Range: (2-3) Interpretation: FOR ADDITIONAL INFORMATION - CHECK INR UNDER "TEST DESCRIPTION INFO" Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ----------------------------------------------------------------------------- Comments: For Test: COAGULATION (PT & PTT) ANTICOAGULANT: PT ============================================================================= Lab Test: Hemogram V Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Whole blood Date/Time Collected: 22 Mar 2011 @ 1000 ----------------------------------------------------------------------------- Test Name: ERYTHROCYTE DISTRIBUTION WIDTH Result: 40 High Units: % Reference Range: (11.5-14.5) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: ERYTHROCYTE MEAN CORPUSCULAR HEMOGLOBIN Result: 20 Low Units: pg Reference Range: (27-31) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: ERYTHROCYTE MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION Result: 30 Low Units: gm/dl Reference Range: (33-37) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: ERYTHROCYTES Result: 4.44 Low Units: m/cmm Reference Range: (4.7-6.1) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: HEMATOCRIT Result: 47.1 Units: % Reference Range: (42-52) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: HEMOGLOBIN Result: 15.5 Units: g/dl Reference Range: (14-18) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: LEUKOCYTES Result: 20 High Units: t/cmm Reference Range: (4.8-10.8) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: LYMPHOCYTES/100 LEUKOCYTES Result: 14.9 Low Units: % Reference Range: (20.5-51.1) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: MEAN CORPUSCULAR VOLUME Result: 100.2 High Units: fl Reference Range: (80-94) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: PLATELET MEAN VOLUME Result: 60 High Units: fl Reference Range: (7.4-10.4) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: PLATELETS Result: 50 Low Units: t/cmm Reference Range: (130-400) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ----------------------------------------------------------------------------- Comments: This is a comment entered for this lab panel. ============================================================================= Lab Test: Carbon Dioxide Content Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 01 Dec 2010 ----------------------------------------------------------------------------- Test Name: CARBON DIOXIDE Result: Units: mEq/L Reference Range: (23-33) Interpretation: Reference range prior to 5/25/01 was 22-31 mEq/L. Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Renal Panel Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 01 Dec 2010 ----------------------------------------------------------------------------- Test Name: CALCIUM Result: 150 Critical High Units: mg/dl Reference Range: (8.5-10.5) Interpretation: Critical high prior to 6/13/00 = 13 mg/dl Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: CHLORIDE Result: 13 Low Units: mEq/L Reference Range: (98-108) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: CREATININE Result: 63 High Units: mg/dl Reference Range: (.5-1.4) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: CREATININE EGFR Result: 0.7 Low Units: Reference Range: (>60) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: GLUCOSE Result: 110 Units: mg/dl Reference Range: (65-110) Interpretation: ***PLEASE NOTE NEW CRITICAL VALUE EFFECTIVE 2/2/98*** Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: POTASSIUM Result: 50 Critical High Units: mEq/L Reference Range: (3.6-5.1) Interpretation: Normal Range Prior to 8-22-02 was: 3.6 - 5.0 mEq/L. Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: SODIUM Result: 130 Low Units: mEq/L Reference Range: (136-145) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ---------------------- Test Name: UREA NITROGEN Result: 27 High Units: mg/dl Reference Range: (6-20) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ============================================================================= Lab Test: Albumin Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: ALBUMIN Result: Units: g/dl Reference Range: (3.4-5.0) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Bilirubin Total Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: BILIRUBIN Result: Units: mg/dl Reference Range: (.2-1.5) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Calcium Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: CALCIUM Result: Units: mg/dl Reference Range: (8.5-10.5) Interpretation: Critical high prior to 6/13/00 = 13 mg/dl Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Carbon Dioxide Content Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: CARBON DIOXIDE Result: Units: mEq/L Reference Range: (23-33) Interpretation: Reference range prior to 5/25/01 was 22-31 mEq/L. Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Chemistry Analysis Profile Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: GLUCOSE Result: 110 Units: mg/dl Reference Range: (65-110) Interpretation: ***PLEASE NOTE NEW CRITICAL VALUE EFFECTIVE 2/2/98*** Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Final ============================================================================= Lab Test: Chloride Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: CHLORIDE Result: Units: mEq/L Reference Range: (98-108) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Creatinine Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: CREATININE Result: Units: mg/dl Reference Range: (.5-1.4) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Gen Chem Specimen Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: CREATININE EGFR Result: Units: Reference Range: (>60) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Phosphatase Alkaline Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: ALKALINE PHOSPHATASE Result: Units: U/L Reference Range: (32-122) Interpretation: REFERENCE RANGE PRIOR TO 9/26/00 = 43-122 U/L Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Potassium Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: POTASSIUM Result: Units: mEq/L Reference Range: (3.6-5.1) Interpretation: Normal Range Prior to 8-22-02 was: 3.6 - 5.0 mEq/L. Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Protein Total Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: PROTEIN Result: Units: g/dl Reference Range: (6.0-8.5) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Sodium Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: SODIUM Result: Units: mEq/L Reference Range: (136-145) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Transferase Alanine Amino SGPT Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: ALANINE AMINOTRANSFERASE Result: Units: U/L Reference Range: (8-63) Interpretation: MALE REFERENCE RANGE PRIOR TO 9/26/00 = 21-72 U/L FEMALE REFERENCE RANGE PRIOR TO 9/26/00 = 9-52 U/L Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Transferase Aspartate SGOT Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: ASPARTATE AMINOTRANSFERASE Result: Units: U/L Reference Range: (9-45) Interpretation: MALE REFERENCE RANGE PRIOR TO 9/26/00 = 14-50 U/L FEMALE REFERENCE RANGE PRIOR TO 9/26/00 = 8-39 U/L Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Lab Test: Urea Nitrogen Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: DAYTON, OH VAMC Specimen: Serum Date/Time Collected: 04 Jun 2010 @ 0900 ----------------------------------------------------------------------------- Test Name: UREA NITROGEN Result: Units: mg/dl Reference Range: (6-20) Interpretation: Performing Location: DAYTON, OH VAMC 4100 W. THIRD STREET , DAYTON, OH 45428 Status: Pending ============================================================================= Test results slightly outside the reference range are not unusual. Your provider has reviewed your test results and will contact you for any important issues. If you have further questions, please do not hesitate to contact your primary care provider. ----------------------------- LABS AND TESTS -------------------------------- Source: Self-Entered Test Name: Blood Test Date: 06 Jun 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: 01 Jul 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: 02 Aug 2010 Time: 1720 Systolic: 130 Diastolic: 76 Comments: BP taken lying down =============================================================================== Measurement Type: Blood pressure Date: 02 Aug 2010 Time: 1730 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: 02 Jun 2010 Time: 1720 Heart Rate: 160 Comments: Started taking Beta-Blockers after visit with physician =============================================================================== Measurement Type: Body weight Date: 02 Apr 2010 Time: 1720 Body Weight: 246 Measure: Pounds Comments: Talk to provider about weight management program at next visit =============================================================================== Measurement Type: Body weight Date: 02 May 2010 Time: 1720 Body Weight: 244 Measure: Pounds Comments: Lost a few pounds and feel better. Walking daily =============================================================================== Measurement Type: Body weight Date: 02 Jun 2010 Time: 1720 Body Weight: 242 Measure: Pounds Comments: still walking when I have time off from work =============================================================================== Measurement Type: Body temperature Date: 02 Mar 2010 Time: 1720 Body temperature: 98.5 Measure: Fahrenheit Method: Mouth Comments: I wasn't feeling well but temperature is normal =============================================================================== Measurement Type: Pain Date: 01 Jan 2010 Time: 1720 Pain Level: 7 Comments: Lower back pain - took 1 Ibuprofen with food for pain =============================================================================== Measurement Type: Blood sugar Date: 02 Jan 2010 Time: 1720 Method: Sterile Lancet Blood sugar count: 166 Comments: BS taken before meal =============================================================================== Measurement Type: Cholesterol Date: 15 Aug 2010 Time: 2359 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: Exposure to Burning Chemicals Event Date: 01 Jan 2007 Service Branch: Army Rank: COL Exposures: Yes Location of Service: Overseas Onboard Ship: No Military Occupational Specialty: Intelligence Officer Assignment: 1st Recon Exposures: Exposed to burning chemicals Military Service Description: Unit was in charge of security --------------------- DOD MILITARY SERVICE INFORMATION --------------------- Source: DoD Last Updated: 02 Dec 2011 @ 1013 NOTE: This report may not show your complete DoD Military Service Information. For more information go to the FAQ tab. -- Regular Active Service Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 06/11/2005 03/26/2007 Honorable COL Army 02/22/2009 02/21/2010 Honorable COL Army 04/10/2010 04/08/2011 Honorable COL -- Reserve/Guard Association Periods Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Guard 01/11/1987 08/24/1993 Unknown Army Reserve 08/25/1993 10/25/2004 Unknown COL Army Reserve 03/27/2007 10/31/2008 Unknown COL -- Reserve/Guard Activation Periods Service Begin Date End Date Activated Under (Title 10, 32, etc.) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 11/10/2001 11/09/2002 Army Reserve 04/14/2003 10/13/2004 Army Reserve 10/24/2004 10/25/2004 Army Reserve 03/27/2007 10/24/2007 Army Reserve 02/04/2008 10/31/2008 -- Deployment Periods Service Begin Date End Date Conflict Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 03/01/2004 03/31/2004 OEF ZZ Army 01/01/2007 03/26/2007 OEF IZ -- DoD MOS/Occupation Codes -- Note: Both Service and DoD Generic codes may not be present in all records Service Begin Date Enl/Off Type Svc Occ Code DoD Occ Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 01/16/1975 Officer Duty 35B00 3A Army Reserve 01/16/1975 Officer Primary 35D00 3A Army Reserve 03/31/2002 Officer Duty 35D 3A Army Reserve 03/31/2002 Officer Primary 35D 3A Army Reserve 06/30/2002 Officer Duty 00A 9E Army Reserve 11/30/2002 Officer Duty 01A 9E Army Reserve 10/31/2003 Officer Duty 35D 3A Army 06/11/2005 Officer Primary 35D5K 3A Army 05/31/2006 Officer Duty 35D 3A Army Reserve 03/27/2007 Officer Primary 35D5K 3A Army Reserve 06/27/2007 Officer Duty 35D5K 3A Army 02/22/2009 Officer Duty 35D00 3A Army 02/22/2009 Officer Secondary 66HD5 6E18 Army 02/22/2009 Officer Primary 35D5K 3A -- Military/Combat Pay Details Service Begin Date End Date Military Pay Type Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 03/01/2004 03/31/2004 02 Army 01/01/2007 02 Army 01/01/2007 01 IZ -- Separation Pay Details Service Begin Date End Date Separation Pay Type - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Retirement Periods Service Begin Date End Date Retirement Type Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 11/01/2008 02/21/2009 F COL Army 02/22/2010 04/09/2010 F COL Army 04/09/2011 F COL -- DoD Retirement Pay Service Begin Date End Date Dsblty % Pay Stat Term Rsn Stop Pay Rsn - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 10/31/2008 11/30/2008 00 1 C Z Army 12/01/2008 00 1 W Z Army 03/01/2010 07/31/2010 00 1 C Z Army 08/01/2010 00 5 W B Army 05/01/2011 05/31/2011 00 1 C Z Army 06/01/2011 00 1 W Z Translations of Codes Used in this Section: Service Occupation Codes 00A Officer Duties Unassigned 01A Officer Officer Generalist 35B00 Officer Land Combat Support Systems (LCSS) Test Specialist 35B00 Officer Strategic Intelligence (RC) 35D Officer Air Traffic Control Equipment Repairer 35D Officer All Source Intelligence 35D Officer Meteorological Equipment Repairman 35D00 Officer Air Traffic Control Equipment Repairer 35D00 Officer All Source Intelligence 35D00 Officer Meteorological Equipment Repairman 35D5K Officer Air Traffic Control Equipment Repairer 35D5K Officer All Source Intelligence 35D5K Officer Meteorological Equipment Repairman 66HD5 Officer Medical Surgical Nurse 66HD5 Officer Observation Airplane Technical Inspector DoD Occupation Codes 3A Officer Intelligence, General 9E Officer Other Military Pay Type Code 01 Combat Zone Tax Exclusion (CZTE) 02 Hostile Fire/Imminent Danger 03 Hazardous Duty incentive Separation Pay Type Code 01 Separation Pay 02 Readjustment Pay 03 Non-Disability Severance Pay 04 Disability Severance Pay 05 Discharge Gratuity 06 Death Gratuity 07 Special Separation Benefit 08 Voluntary Separation Incentive Pay 09 Voluntary Separation Pay (VSP) Retirement Type Code A Mandatory B Voluntary C Fleet Reserve D Temporary Disability Retirement List E Permanent Disability Retirement List F Title III G Special Act H Philippine Scouts Retired Pay Status Code 1 Receiving retired pay 2 Eligible, not receiving pay 3 Eligible, not receiving direct SBP remittance 4 Terminated 5 Suspended Retired Pay Termination Reason Code C Pay condition terminated S Pay terminated for the reason reported in the Stop Payment Reason Code W Not terminated Stop Payment Reason Code A Member died B Recalled to Active Duty C Removed from TDRL, returned to Active Duty D Removed from TDRL, returned to Civilian E Pay suspended, failure to report for TDRL physical F Civil Service retirement waiver G VA compensation waiver H Dual compensation, pay cap offset J Refused retired pay K Pay suspended, whereabouts unknown L Suspected death M Pay suspended, miscellaneous Z Not applicable -------------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------