------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v11.1) 01/10/2011 09:55 Name: MHVVETERAN, ONE A Date of Birth: 03/01/1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 01/10/2011 09:55 AM CST User Request Type: Download only my selected data from My HealtheVet File Name: mhv_MHVVETERAN_20110110.txt Date Range Selected: 09/10/2010 to 01/10/2011 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 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 ------------------------- 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 VA Past Appointments are limited to two years from the date of your download request. PAST APPOINTMENTS: -------------------- 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 -------------------------- 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 ------------