------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v1.0) 08/23/2010 09:31 Name: MHVVETERAN, ONE A Date of Birth: 03/01/1948 --------------------- 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 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 -------------------------- ALLERGIES/ADVERSE REACTIONS --------------------- Source: Self-Entered Allergy Name: Pollen Date: 03/18/2010 Severity: Mild Diagnosed: Yes Reaction: Watery eyes, itchy nose Comments: Took an over the counter antihistamine 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 ------------------------------ MEDICAL EVENTS ------------------------------- Source: Self-Entered Medical Event: Colonoscopy Start Date: 03/18/2000 Stop Date: 03/18/2000 Response: Colonoscopy went 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: Tetanus Other: none Method: Injection Date Received: 07/18/2010 Reactions: --------------------------------- Pain Comments: stepped on a rusty nail Immunization: Flu Other: H1N1 Method: Inhalant Date Received: 09/01/2009 Reactions: --------------------------------- Comments: Had no reaction Immunization: Measles + Rubella (German Measles) Other: none Method: Injection Date Received: 03/01/1950 Reactions: --------------------------------- Pain Comments: Received as a child -------------------------- FAMILY HEALTH HISTORY ---------------------------- Source: Self-Entered Relationship: Self First Name: ONE Last Name: MHVVETERAN 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 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 -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA Medication: AMLODIPINE BESYLATE 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH TAKE ONE-HALF TABLET FOR 1 DAY --AVOID 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 AS DIRECTED FOR TESTING AS DIRECTED AS DIRECTED FOR 50 DAYS USE 1 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 FOR 60 DAYS TAKE ONE TABLET 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 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 FOR 1 DAY 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 DAILY FOR 90 DAYS TAKE ONE TABLET BY 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 90 DAYS TAKE ONE TABLET BY 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 ONE CAPSULE BY MOUTH THREE TIMES A DAY AND AT BEDTIME FOR 90 DAYS 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: 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: 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 Medication: SODIUM CHLORIDE 0.65% SOLN NASAL SPRAY Instructions: SPRAY 2 SPRAYS IN MOUTH MINUTE FOR 30 DAYS 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: PSEUDOEPHEDRINE 60MG TAB Instructions: TAKE ONE TABLET BY MOUTH MINUTE Status: Unknown 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: NAPROXEN 500MG TAB Instructions: TAKE ONE TABLET BY MOUTH MINUTE FOR 30 DAYS --TAKE WITH FOOD IF GI Status: Unknown 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: BACITRACIN 500 UNIT/GM OINT 30GM Instructions: APPLY SMALL AMOUNT TO AFFECTED AREA 2-3 TIMES A DAY FOR 30 DAYS Status: Unknown 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: FAMOTIDINE 20MG TAB Instructions: TAKE ONE TABLET BY MOUTH FIVE TIMES DAILY --MAY TAKE WITH FOOD/AVOID Status: Unknown 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 Medication: ESOMEPRAZOLE MAGNESIUM 40MG SA CAP Instructions: TAKE ONE CAPSULE BY MOUTH MINUTE FOR 45 DAYS Status: Unknown 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 DAILY FOR 90 DAYS --AVOID GRAPEFRUIT Status: Unknown 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: OXYCODONE 5MG/ACETAMINOPHEN 325MG TAB Instructions: TAKE 1 TO 2 TABLETS BY MOUTH EVERY SIX HOURS Status: Expired Refills Remaining: 0 Last Filled On: 07/06/2000 Initially Ordered On: 07/06/2000 Quantity: 30 Days Supply: 7 Pharmacy: DAYTON Prescription Number: 800097347 -------------------------- 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 ---------------------------- VA WELLNESS REMINDERS ------------------------- Source: VA Wellness Reminder Due Date Last Completed Location ---------------------------------------------------------------------------- Body Mass >25 Alert DUE NOW UNKNOWN DAYT29 Colon Cancer Screening 8/13/2010 8/13/2009 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 8/13/2009 DAYT29 Lipid Measurement (Cholesterol) 8/13/2011 8/13/2009 DAYT29 Pneumonia Vaccine DUE NOW UNKNOWN DAYT29 Note: Learn more about these Wellness Reminders by visiting My HealtheVet. Please contact your health care team with any questions about your VA Wellness Reminders. ----------------------------- VITALS AND READINGS --------------------------- Source: Self-Entered ================================================================================ Measurement Type: Blood pressure Date: 08/02/2010 Time: 17:30 Systolic: 132 Diastolic: 76 Comments: BP taken standing. PB continues at goal. Doctor says to continue BP medications as directed ================================================================================ Measurement Type: Blood pressure Date: 08/02/2010 Time: 17:20 Systolic: 130 Diastolic: 76 Comments: BP taken lying down ================================================================================ 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: 06/02/2010 Time: 17:20 Body Weight: 242 Measure: Pounds Comments: still walking when I have time off from work ================================================================================ 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: 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 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. ----------------------------- 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 -------------- END MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------