DONNA M DEAN Female 5021 MEADOWLARK CT HENRICO VA 232319999 1964-12-30 56 null 11004300 5K63A34XY03 8043251281 8046480535 null null null ASHRAFI, ABBAS 8046522200 4630 S Laburnum Ave Ste D Henrico VA 232312441 Henrico P0113848 LABURNUM MEDICAL CENTER levelOneSingleSelect 1. Race African American Caucasian null African American null Asian null Latino null Native American null Native Hawaiian or other Pacific Islander null Alaskan Native null Other Describe null levelOneSingleSelect Patient's Ethnicity null Hispanic null Non-Hispanic null Other Ethnicity null Prefer not to say null levelOneSingleSelect 2. Preferred language null English null Other If other, null African languages null Arabic null Chinese null French null French Creole null German null Greek null Gujarati null Hebrew null Hindi null Hungarian null Italian null Japanese null Korean null Persian null Polish null Portuguese null Russian null Scandinavian Languages null Serbo-Croatian null Spanish null Tagalog null Urdu null Vietnamese null Yiddish null currentCondition Date of Service Diagnosis Code Diagnosis 2020-08-20 J98.11 Atelectasis 2020-08-16 R91.8 Other nonspecific abnormal finding of lung field 2020-08-04 A41.9 Sepsis, unspecified organism 2020-08-09 R65.21 Severe sepsis with septic shock 2020-08-10 J96.01 null 2020-08-07 D62 null 2020-11-11 D72.829 Elevated white blood cell count, unspecified 2020-08-10 Z99.11 Dependence on respirator [ventilator] status 2021-01-29 Z90.49 Acquired absence of other specified parts of digestive tract 2021-01-27 Z93.3 Colostomy status 2020-08-23 J90 null 2020-08-24 Z98.890 Other specified postprocedural states 2021-02-02 R32 null 2021-02-02 N39.3 Stress incontinence (female) (male) 2020-10-01 B37.7 Candidal sepsis 2020-09-25 B49 null 2020-09-09 N17.9 Acute kidney failure, unspecified 2020-08-12 J81.1 Chronic pulmonary edema 2020-08-07 I08.8 Other rheumatic multiple valve diseases 2020-08-07 J98.19 Other pulmonary collapse 2020-08-07 R60.9 Edema, unspecified 2020-10-09 R18.8 Other ascites 2020-08-08 I50.9 Heart failure, unspecified 2020-08-11 A41.89 Other specified sepsis 2020-08-10 E66.01 null 2020-08-11 R57.8 Other shock 2020-08-11 E87.3 Alkalosis 2020-08-16 J98.4 Other disorders of lung 2020-08-11 Z04.9 Encounter for examination and observation for unspecified reason 2021-02-22 Z74.1 Bed confinement status 2020-08-12 I51.7 Cardiomegaly 2020-08-12 R07.9 Chest pain, unspecified 2020-10-01 L03.113 Cellulitis of right upper limb 2020-08-20 J98.6 Disorders of diaphragm 2020-11-11 M35.9 Sicca syndrome with other organ involvement 2021-01-14 M32.9 Systemic lupus erythematosus, unspecified 2020-12-10 M06.9 Rheumatoid arthritis without rheumatoid factor, multiple sites 2021-03-18 I10 null 2021-01-27 D64.9 Anemia, unspecified 2021-02-02 H91.90 Unspecified hearing loss, unspecified ear 2020-08-20 R10.9 Unspecified abdominal pain 2020-05-01 M19.90 Unspecified osteoarthritis, unspecified site 2020-09-28 H04.129 Dry eye syndrome of unspecified lacrimal gland 2020-12-10 E55.9 Vitamin D deficiency, unspecified 2021-01-27 Z78.9 Other specified health status 2020-08-23 M79.609 Pain in unspecified limb 2020-08-23 R59.0 Localized enlarged lymph nodes 2020-10-01 K65.1 Peritoneal abscess 2020-09-02 K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding 2020-08-24 H91.3 Ototoxic hearing loss, bilateral 2020-08-24 L03.313 Cellulitis of chest wall 2020-08-25 Z46.82 Encounter for fitting and adjustment of non-vascular catheter 2020-10-01 K57.01 null 2021-01-27 K21.9 Gastro-esophageal reflux disease without esophagitis 2020-10-01 E46 null 2020-10-01 K56.600 Partial intestinal obstruction, unspecified as to cause 2020-10-01 L20.84 Intrinsic (allergic) eczema 2020-10-01 M15.8 Other polyosteoarthritis 2020-10-01 L30.9 Dermatitis, unspecified 2020-10-01 R26.2 Difficulty in walking, not elsewhere classified 2020-10-01 M62.81 Muscle weakness (generalized) 2020-10-01 R27.8 Other lack of coordination 2020-08-28 R53.81 Other malaise 2020-08-28 Z91.81 History of falling 2020-08-28 Z74.01 null 2020-09-28 R51 null 2020-11-11 I82.C11 Acute embolism and thrombosis of right internal jugular vein 2020-09-25 Z90.89 Acquired absence of other organs 2020-09-28 R11.0 Nausea 2020-09-25 R78.81 Bacteremia 2020-09-04 B37.9 Candidiasis, unspecified 2020-12-01 I82.621 Acute embolism and thrombosis of deep veins of right upper extremity 2020-11-26 I82.611 Acute embolism and thrombosis of superficial veins of right upper extremity 2020-09-09 Z95.9 Presence of cardiac and vascular implant and graft, unspecified 2020-09-08 S50.811A Abrasion of right forearm, initial encounter 2020-09-08 S31.609D Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal cavity, subsequent encounter 2021-01-27 K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding 2020-09-16 F33.9 Major depressive disorder, recurrent, unspecified 2020-10-22 R53.1 Weakness 2020-09-25 H04.209 Unspecified epiphora, unspecified side 2020-10-15 Z72.3 Lack of physical exercise 2020-09-28 M25.552 Pain in left hip 2021-01-29 K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding 2020-10-15 R05 null 2020-10-15 R06.02 null 2021-01-14 M35.1 Sicca syndrome with keratoconjunctivitis 2020-09-30 Z79.2 Long term (current) use of antithrombotics/antiplatelets 2020-09-30 Z79.899 Other long term (current) drug therapy 2019-10-01 N95.1 Menopausal and female climacteric states 2020-10-15 R11.2 Nausea with vomiting, unspecified 2020-10-22 L29.9 Pruritus, unspecified 2020-06-08 M05.9 Felty's syndrome, multiple sites 2020-10-09 N83.8 Other noninflammatory disorders of ovary, fallopian tube and broad ligament 2020-10-22 H40.059 null 2021-01-14 Z87.19 Personal history of other diseases of the digestive system 2018-10-25 H05.019 null 2020-11-26 Z79.01 null 2021-02-02 R26.81 Unsteadiness on feet 2021-02-02 R31.9 Hematuria, unspecified 2020-11-26 Z43.3 Encounter for attention to colostomy 2020-10-30 M32.10 Systemic lupus erythematosus, organ or system involvement unspecified 2021-01-14 E83.42 Hypomagnesemia 2020-12-01 R79.89 Other specified abnormal findings of blood chemistry 2020-02-26 R68.89 Other general symptoms and signs 2021-01-14 R74.8 Abnormal levels of other serum enzymes 2020-12-01 H60.11 Cellulitis of right external ear 2021-01-14 R74.01 null 2020-01-15 H60.91 Unspecified otitis externa, right ear 2020-03-06 H61.23 Chronic perichondritis of external ear, bilateral 2020-01-22 H60.12 Cellulitis of left external ear 2020-07-15 K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding 2020-08-20 D25.9 Leiomyoma of uterus, unspecified 2019-01-30 R10.84 Generalized abdominal pain 2019-02-07 R07.89 Other chest pain 2019-01-30 N39.0 Urinary tract infection, site not specified 2020-06-24 E03.9 Hypothyroidism, unspecified 2020-06-24 Z88.6 Allergy status to analgesic agent status 2019-02-14 H91.93 Unspecified hearing loss, bilateral 2020-05-12 R10.31 Right lower quadrant pain 2019-02-22 R06.00 null 2019-02-14 J94.8 Other specified pleural conditions 2019-02-14 R59.1 Generalized enlarged lymph nodes 2020-04-02 J32.9 Chronic sinusitis, unspecified 2019-03-08 J18.9 Pneumonia, unspecified organism 2019-03-11 R26.9 Unspecified abnormalities of gait and mobility 2019-03-11 G89.29 Other chronic pain 2019-03-11 L89.301 Pressure ulcer of unspecified buttock, stage 1 2020-05-02 R19.7 Generalized intra-abdominal and pelvic swelling, mass and lump 2020-05-02 L02.211 Cutaneous abscess of abdominal wall 2020-06-24 R10.30 Lower abdominal pain, unspecified 2020-06-24 E87.6 Hypokalemia 2020-06-24 E66.9 Other obesity due to excess calories 2020-05-02 R80.9 Proteinuria, unspecified 2020-05-02 Z79.811 Long term (current) use of aromatase inhibitors 2020-05-03 Z98.51 Tubal ligation status 2020-05-02 Z68.39 Body mass index (BMI) 39.0-39.9, adult 2020-05-02 N32.89 Other specified disorders of bladder 2020-05-03 R93.89 Abnormal findings on diagnostic imaging of other specified body structures 2020-05-02 R10.33 Periumbilical pain 2020-05-02 R10.12 Left upper quadrant pain 2020-05-03 N70.03 null 2020-07-18 N70.93 Salpingitis and oophoritis, unspecified 2020-05-04 B96.89 Other specified bacterial agents as the cause of diseases classified elsewhere 2020-05-05 L02.91 Cutaneous abscess, unspecified 2020-05-12 L30.4 Erythema intertrigo 2020-07-18 K76.0 Fatty (change of) liver, not elsewhere classified 2020-05-12 H91.8X3 Other specified hearing loss, bilateral 2020-05-12 Z68.38 Body mass index (BMI) 38.0-38.9, adult 2020-07-29 R10.32 Left lower quadrant pain 2020-06-24 N73.9 Female pelvic inflammatory disease, unspecified 2020-05-18 T14.90XA Injury, unspecified, initial encounter 2020-06-18 Z48.03 null 2020-07-20 K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding 2020-08-20 M16.0 Bilateral primary osteoarthritis of hip 2020-07-10 B37.2 Candidiasis of skin and nail 2020-06-24 R16.0 Hepatomegaly, not elsewhere classified 2020-06-16 N28.1 Cyst of kidney, acquired 2020-06-24 K56.7 Ileus, unspecified 2020-06-24 Z68.37 Body mass index (BMI) 37.0-37.9, adult 2020-06-24 Z11.59 Encounter for screening for other viral diseases 2020-06-24 R19.00 null 2020-07-15 N73.8 Other specified female pelvic inflammatory diseases 2020-08-03 R00.0 Tachycardia, unspecified 2020-07-29 E43 null 2020-07-29 K35.33 Acute appendicitis with perforation and localized peritonitis, with abscess 2020-07-29 K56.51 Intestinal adhesions [bands], with partial obstruction 2021-01-29 K63.89 Other specified diseases of intestine 2020-08-02 K56.50 Intestinal adhesions [bands], unspecified as to partial versus complete obstruction 2020-08-02 K38.8 Other specified diseases of appendix 2020-08-02 K35.80 Unspecified acute appendicitis 2020-08-02 Z45.2 Encounter for adjustment and management of automatic implantable cardiac defibrillator 2020-08-02 M19.011 null 2020-08-02 M19.012 null 2020-08-03 I95.9 Hypotension, unspecified 2020-08-20 G89.18 Other acute postprocedural pain 2020-08-20 M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified 2020-12-10 R94.5 Abnormal results of liver function studies 2020-12-10 D84.1 Defects in the complement system 2020-12-10 R94.4 Abnormal results of kidney function studies 2020-12-10 I82.409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity 2021-01-27 Z13.9 Encounter for screening, unspecified 2021-01-29 K64.4 Residual hemorrhoidal skin tags 2021-01-29 Z98.0 Intestinal bypass and anastomosis status 2021-01-29 Z09 null 2020-07-29 R11.10 Vomiting, unspecified suspectCodes Date of Service Diagnosis Code Diagnosis yesNo In the last 14 days, have you: Traveled internationally? null Yes null No null Had known exposure to anyone diagnosed with Corona virus (COVID-19) null Yes null No null Had close contact with someone who has traveled to a high risk area? null Yes null No null Developed Fever? null Yes null No null Developed Cough? null Yes null No null Developed Flu like symptoms? null Yes null No null Developed Shortness of breath? null Yes null No null levelOneSingleSelect 3. How much school have you completed? null Less than 3rd grade null Completed 3rd grade null Completed 8th grade null Completed 12th grade null Attended College null levelOneSingleSelect 4. When you get written information at a doctor's office would you say it is null Very difficult null Somewhat difficult null Easy null Very easy to understand null levelOneSingleSelect 5. When you read the instructions on a prescription bottle would you say that it is null Very difficult null Somewhat difficult null Easy null Very easy to understand null levelOneSingleSelect 6. How confident are you in filling out medical forms by yourself? null Not at All Confident null Not Very Confident null Confident null Very Confident null levelOneSingleSelect 7. How would you rate your health compared to other persons your age? null Excellent null Good null Fair null Poor null levelOneSingleSelect 8. During past 3 months, has your physical and or emotional health limited your social activities with family, friends, neighbours or groups? null Often null Sometimes null Almost Never null Never null levelOneSingleSelect 9. Where do you currently live? null Home null Apartment null Assisted Living null Nursing Home null Homeless Describe null Other Describe null levelOneSingleSelect 10. Do you have someone you can rely on to help if you are sick or have problems you need to discuss? null Yes null No null levelOneSingleSelect 11. Who do you currently live with? null Alone Describe null Spouse null Partner null Relative null Family null Friend null Personal Care Worker null levelOneSingleSelect 12. Are you currently a caregiver for someone? null Yes Describe null No null levelThreeSingleSelect 13. Tobacco use null Current Type null Cigarettes How Many null 1 - 3 a day null 1/2 a pack null 1 pack null More than 1 pack null Other null Describe null Cigars null Chewing Tobacco null Vaping null Other Describe null Former Type null Cigarettes How Many null 1 - 3 a day null 1/2 a pack null 1 pack null More than 1 pack null Other null Describe null Cigars null Chewing Tobacco null Vaping null Other Describe null Never null SingleSelectDropdown 14. Alcohol Use Current null How many drinks How Often select select Former null How many drinks How Often select select Never null levelOneSingleSelect 15. Do you or have you used recreational drugs or pain medication? null Yes Which drugs or medication null No null levelOneSingleSelect 16. Do you have a Healthcare Proxy? null Yes Name null Relationship null No null Don't Know null levelOneSingleSelect 17. Do you have a Durable Power of Attorney? null Yes Name null Relationship null No null Don't Know null levelOneSingleSelect 18. Do you have an Advance Directive? null Yes Where is it kept? null No null Don't Know null levelOneSingleSelect Within the past 12 months we worried whether our food would run out before we got money to buy more. Was that ______ for your household? null Often True null Sometimes True null Never True null levelOneSingleSelect Within the past 12 months the food we bought just didn't last and we didn't have money to get more. Was that ______ for your household? null Often True null Sometimes True null Never True null yesNo 19. Do you have any difficulty with the following activities? A. Getting in or out of bed null No null Need Some Help null Need Total Help null B. Getting in or out of chairs null No null Need Some Help null Need Total Help null C. Toileting null No null Need Some Help null Need Total Help null D. Bathing null No null Need Some Help null Need Total Help null E. Dressing null No null Need Some Help null Need Total Help null F. Eating null No null Need Some Help null Need Total Help null G. Walking null No null Need Some Help How far can you walk null Household only null Less than one block null One block null Two or more blocks null Non-ambulatory null Need Total Help How far can you walk null Household only null Less than one block null One block null Two or more blocks null Non-ambulatory null H. Going up or down stairs null No null Need Some Help How many stairs can you climb null None null Three to five null Six to ten null More than ten null Need Total Help How many stairs can you climb null None null Three to five null Six to ten null More than ten null multipleSelect 20. Do you use any assistive devices? (Check device or none if no devices used) null None Cane Walker Prosthesis Wheel Chair Bedside Commode Urinal Bed Pan Other Describe null dropDown 21. Are you currently seeing any specialists? Medical Specialty Specialist For yesNo 22. In the past 12 months how many times have you? A. Seen your PCP null None null 1 null 2 null 3 null 4 null 5 or more null B. Visited the Emergency Room null None null 1 If one or more, describe null 2 If one or more, describe null 3 If one or more, describe null 4 If one or more, describe null 5 or more If one or more, describe null C. Stayed in the hospital overnight null None null 1 If one or more, describe null 2 If one or more, describe null 3 If one or more, describe null 4 If one or more, describe null 5 or more If one or more, describe null D. Been in a nursing home null None null 1 If one or more, describe null 2 If one or more, describe null 3 If one or more, describe null 4 If one or more, describe null 5 or more If one or more, describe null E. Had Surgery null None null 1 If one or more, describe null 2 If one or more, describe null 3 If one or more, describe null 4 If one or more, describe null 5 or more If one or more, describe null levelOneSingleSelect 23. Have you ever been hospitalized prior to the last 12 months? null Yes Describe null No null yesNo 24. In the past year have you received health services from any of the providers below: Physical Therapist null Yes null No null Occupational Therapist null Yes null No null Dietician null Yes null No null Social Worker null Yes null No null Pharmacist null Yes null No null Speech Therapist null Yes null No null Chiropractor null Yes null No null Personal Care Worker (HHA, CNA, PCA) null Yes null No null Meals on Wheels null Yes null No null yesNo 25. In the past two years have you received any of the treatments below? Chemotherapy null Yes null No null Unknown null Catheter Care null Yes null No null Unknown null Oxygen null Yes null No null Unknown null Wound Care null Yes null No null Unknown null Regular Injections null Yes null No null Unknown null Tube Feedings null Yes null No null Unknown null dropDown 26. Family History Family Member Medical Condition Cause of Death dropDown 27. In the past three years have you had? Screen Answer Colonoscopy undefined Breast Exam/Mammography undefined Cervical Screening undefined Bone Density undefined Prostate Exam/PSA undefined If Diabetic Eye Exam undefined If Diabetic Foot Exam undefined If Diabetic Hgb A1c screen undefined Lipid Panel undefined levelOneSingleSelect 28. Last colonoscopy if more than 2 years ago null 3 – 5 years ago null 6 – 10 years ago null > 10 years ago null Never null Don't know null levelOneSingleSelect 29. Screen for abnormal glucose / diabetes - age 40 - 70 null Yes null No null NA null levelOneSingleSelect 30. One time screen for Abdominal Aortic Aneurysm if male with history of smoking, age 65 - 75 null Yes null No null NA null levelOneSingleSelect 31. One time screen for Hepatitis C if born between 1945 - 1965 null Yes null No null NA null levelOneSingleSelect 32. Do you get Flu Vaccine each year? null Yes null No null levelOneSingleSelect 33. Have you been vaccinated for Pneumonia? null Yes Pneumovax null Yes null No null Unknown null Prevenar null Yes null No null Unknown null No null levelOneSingleSelect 34. Have you been vaccinated for Herpes Zoster? null Yes Zostervax null Yes null No null Unknown null Shingrex null Yes null No null Unknown null No null SingleSelectTable 35. Allergies undefined null Yes Substance Reaction No medication Dose Date NDC Label Name Dose / Units Quantity Dispensed Route Frequency Status SingleSelectTable 36. Over the Counter Medications / Supplements undefined null Yes Date Description Dose/Units Route Frequency No multipleSelect 37. Chronic Use of null None ASA Steroids Insulin Anticoagulants Statins Biphosphonate yesNo 38. Medication Compliance and Knowledge of Use and Disease 1. Do you ever forget to take your medicine? null Yes null No null 2. Do you sometimes not pay enough attention to your medication? null Yes null No null 3. Do you know the longterm benefit of taking your medicine as told to you by the doctor or pharmacist? null Yes null No null 4. When you feel better do you sometimes stop taking your medicine? null Yes null No null 5. Sometimes if you feel worse when you take your medicine do you stop taking it? null Yes null No null 6. Do you sometimes forget to refill your prescription on time? null Yes null No null YesNoMultipleSelect Eye Problems (Glaucoma, Cataracts, Macular Degeneration, Blindness, Retinal Detachment, Other) null

EYES

Yes Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Secondary to Diabetes null Yes null No null Describe null Active null History of null Rule out null Legally Blind null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Secondary to Diabetes null Yes Type null Open (Wide) Angle null Closed (Narrow) Angle null No null Describe null Active null History of null Rule out null Supported by null Symptoms null Glasses/ lenses null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Wet null Dry null Describe null Active null History of null Rule out null Supported by null Symptoms null Glasses/ lenses null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Secondary to Diabetes null Yes Vitreous Hemorrhage null Yes null No null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Do you wear glasses or contacts? null Yes Do you have trouble seeing even with glasses? null Yes Do you need help in and out of the house because you can't see well? null Yes null No null No null No null Do you have problems seeing at night? null Yes null No null Do you have eye pain? null Yes Which Eye? null Right null Left null Both null No null Do you have problems with tearing? null Yes null No null Do you have a problem with dry eye? null Yes null No null No null YesNoMultipleSelect Ear Problems (Hard of hearing, Deaf, Vertigo, Ear Infections) null

EARS

Yes Describe null Active null History of null Rule out null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Do you lose your balance null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Do you have trouble hearing when people talk to you? null Yes null No null Do you wear a hearing aid? null Yes How often do you wear it null Occasionally null Frequently null All of the time null Do you still have trouble hearing with it? null Yes null No null No null Do you read lips? null Yes null No null Do you have ear pain or drainage? null Yes Which ear null Right null Left null Both null No null Do you ever get dizzy? null Yes Does the room spin? null Yes null No null Do you ever lose your balance? null Yes null No null No null No null YesNoMultipleSelect Nose Problems (Nose Bleeds, Sinus infections, Other) null

NOSE

Yes Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Describe null Active null History Of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Exudate null Clear null Purulent null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null No null YesNoMultipleSelect Mouth and Throat Problems (Difficulty Chewing, Difficulty Swallowing, Bleeding Gums, Other ) null

MOUTH AND THROAT

Yes Describe null Active null History of null Rule out null Describe null Active null History of null Rule out null Because of pain null Yes Because you wear partial or complete dentures null Yes null No null No null Describe null Active null History of null Rule out null Have you had a stroke null Yes Do you eat a special diet null Yes null No null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null No null YesNoMultipleSelect Neck Problems (parotid Disease, Carotid Stenosis, Other) null

NECK

Yes Describe null Active null History of null Rule out null Supported by null Bruits null History of TIAs null Laboratory studies null Other Describe null Describe null Right null Left null Bilateral null Describe null Active null History of null Rule out null Supported by null Physical findings null History null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null No null YesNoMultipleSelect Respiratory Problems (COPD, Emphysema, Asthma, Chronic Bronchitis Pneumonia, Other) null

RESPIRATORY

Yes Describe null Active (in past 6 months) null History of null Rule Out null Supported by null Hospitalization for Pulmonary Embolism null CT Angiogram null Venous Doppler null D-dimer null VQ scan null Use of anticoagulation null Other Describe null Describe null Active null History of null Rule out null Supported by null Fever null Chills null Cough null Decreased breathe sounds null Rales null Wheezing null Chest X-ray null Other Describe null Describe null Active null History of null Rule out null Supported by null Wheezing null Chronic Cough null Cyanosis null Use of Bronchodilator null Use of Inhaled or oral steroids null Use of ventilator null Other Describe null Is patient on controller medications null Yes null No null Does patient use rescue medications null Yes null No null Does patient have current exacerbation null Yes Supported by null Wheezing null Shortness of breath null Use of rescue medications null Use of ventilator null No null Describe null Active null History of null Rule out null Supported by null History of Pulmonary Embolism null Insertion of Vena Cava Filter null Anticoagulation beyond six months null Other Describe null Describe null Active null History of null Rule out null Supported by null History of hospitalization with Respiratory Failure null Chronic use of O2 at >2L/min null CO2 Retention null Use of ventilator null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null Use of accessary muscles null Barrel Chest null XR results null Wheezing null Clubbing null Decreased or prolonged breath sounds null Dyspnea on exertion null O2 use null Brinchodilator medication null Respirator null Other null Has patient been told they have Chronic Bronchitis null Yes null No null Has patient been told they have Emphysema null Yes null No null Is patient on Bronchodilator null Yes Route is null Inhaled null Nebulizer null Oral null No null Is patient on Steroids null Yes Route is null Inhaled null Nebulizer null Oral null No null Does patient have current exacerbation null Yes Supported by null Use of antibiotics null Fever null Increased sputum production null Adventitious sounds on lung exam null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule Out null Supported by null Morbid Obesity null Use of O2 null CO2 Retention null Other Describe null Describe null Active null History of null Rule out null Supported by null O2 saturation of <90% on room air null Other Describe null Describe null Active null History of null Rule Out null Supported by null Hospitalization null Physical findings null Image studies null Lab studies null Other Describe null Etiology null Viral null Pneumococcal null Staph null Other Bacterial null Aspiration null History / finding of Lung abscess null Yes null No null History / finding of Empyema null Yes null No null Describe null Active null History of null Rule out null Supported by null X-ray or CT results null PFT null Biopsy null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active (in past 3 months) null History of null Rule out null Supported by null History of hospitalization with Respiratory Arrest null Use of ventilator null CO2 Retention null Other Describe null Describe null Active null History of null Rule out null Supported by null X-ray null Biopsy null Cutaneous lesions null Other Describe null Describe null Active null History of null Rule out null Supported by null Use of CPAP null Positive sleep studies null History of sleepiness during the day null Heavy snoring / restlessness during sleep null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Use of Oxygen null Yes Describe null PRN null Continuous null Day null Night null Litres / Min null No null Shortness of breath null Yes null No null Wheezing null Yes null No null Chronic Cough null Yes null No null Patient requires durable medical equipment null Yes null No null No null YesNoMultipleSelect Cardiovascular (Hypertension, Angina, Ischemic Heart Disease(CAD), Myocardial Infarction, Other) null

CARDIOVASCULAR

Yes Describe null Active null History of null Rule out null Supported by null ECG null Use of rate controlling drug null Use of anticoagulation null Electrophysiology procedure / cardioversion null Other Describe null Describe null Bradycardia null Tachycardia null Regularly irregular Does patient have Atrial Fibrillation null Yes null No null Irregularly Irregular null Premature contractures null Describe null Active null History of null Rule out null Supported by null Physical exam null Ultra sound, last study date & size null Image studies null Other Describe null Describe null Abdominal null Thoracic null Peripheral null Describe null Active null History Of null Rule out null Supported by null Medications null History characterizing chest pain null Stress test null Other Describe null Describe null Stable null Unstable null Describe null Active null History of null Rule out null Type null Paroxysmal null Chronic null Unknown null Supported by null Medications null ECG null Symptoms null History null Electric cardioversion null Other Describe null Is patient taking null Anticoagulant null Rate controlling medication null Other Describe null Describe null Active (in the past 6 months) null History of null Rule out null Supported by null History null Implanted Defibrillator null Use of respirator null Other Describe null Cardiac Arrest null Yes null No null Describe null Active null History of null Rule out null Supported by null Echo null Cardiac Cath null Other Describe null Secondary to Hypertension null yes null No null Describe null Active null History of null Rule out null Supported by null Ejection fraction null Cardiomegaly null Orthopnea null DOE null PND null S3 null Medications null Peripheral edema null Other Describe null Describe null Diastolic null Systolic null Unknown null Secondary to Hypertension null Yes null No null Is patient on an ACE or ARB null Yes null No null Is patient on a Beta Blocker null Yes null No null Describe null Acute null Chronic null Describe null Active null History of null Rule out null Supported by null Physical findings null Use of anticoagulation Describe null Prophylactic null Therapeutic null Vascular studies null Vena Cava filter null Edema null Other Describe null Persistent for three months or more null Yes null No null Describe null Active null History of null Rule out null Supported by null Lab results null Medication null Other Describe null Is patient on Statin null Yes null No null Describe null Active null History of null Rule out null Supported by null Physical Exam null Medications null Symptoms null Other Describe null Adequately controlled null Yes null No null UnKnown null Describe null Active null History of null Rule out null Supported by null Cardiac Cath null History of coronary stent null Diagnosis of angina null Medications null History of CABG null ECG null Other Describe null Describe null Active (in past 28 days) null History of null Rule out null Supported by null ECG changes null Lab results null History of Hospitalization / Procedure for MI null Medications null Other Describe null Is patient taking a Beta Blocker null Yes null No null Is patient taking null Aspirin null Plavix null Nitrate null Other Describe null Describe null Active null History of null Rule out null Supported by null Vascular studies null Claudication null Extremity Ulcers null Diminished or absent pulses null Amputation null Other Describe null History Diabetes null Yes null No null Describe null Ulceration null Gangrene null Describe null Active null History of null Rule out null Supported by null Cardiac Cath null Use of O2 null Edema null Medication null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Mitral Stenosis null Aortic Stenosis / Sclerosis null Tricuspid Stenosis null Pulmonary Insufficiency null Pulmonary Stenosis null Aortic Insufficiency null Mitral Insufficiency / Prolapse null Tricuspid Insufficiency null Valve replacement null Yes null No null Which valve, type of replacement null Is patient on anticoagulation null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null History of Chest Pain null Yes Pain described as null Achy null Sharp null Tight null Crushing null Does pain go into left arm null Yes null No null Is pain reproduced or worsened when touching chest or costochondral junctions null Yes null No null Is pain brought on by null Exertion null Eating null Stress / Anxiety null Other Describe null Is pain relieved by oral medication null Yes How long before pain is relieved null 1min null 2min null 5min null >5min null What medication / s null No null No null History of Intermittent Claudication null Yes Describe null Complete heart block null Sick sinus syndrome null Bradycardia null Other null No null Implanted Pacemaker null Yes Describe null Ventricular Tachycardia null Asystole null Cardiac Arrest null Last interrogation date null Type and ID number null No null Implanted Defibrillator null Yes Describe null Ventricular Tachycardia null Asystole null Cardiac Arrest null No null Do you have abnormal heart beats? null Yes null No null Does your heart race? null Yes null No null Do you sleep on more then one pillow? null Yes null No null have you ever have fluid in your lungs? null Yes null No null Do your legs or ankles swell up? null Yes null No null Do you follow a special diet? null Yes null No null Do you have headaches? null Yes null No null Do you feel light headed when you stand up? null Yes null No null No null YesNoMultipleSelect Gastrointestinal Problems (Ulcer, Reflux, Hiatal Hernia, Colitis, Other) null

GASTROINTESTINAL

Yes Describe null Active null History of null Rule out null Supported by null Hospitalization null Image studies null Physical Findings null Other Describe null Describe null Active null History of null Rule out null Supported by null Albumin < 3.5 g/dl null Muscle wasting null History of severe weight loss null Other Describe null Describe null Active null History of null Rule out null Supported by null Weight loss null Anemia null Change in bowel movements null Osteoporosis null Diet null Other Describe null On a gluten free diet null Yes null No null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical findings null Lab studies null MRI null Biopsy null Other Describe null End Stage Liver Disease null Yes Supported by history / finding of null Ascites null Varices null Encephalopathy null Hepatorenal Syndrome null Other null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Benign null Carcinoma in situ null Familial Polyposis null Describe null Active null History of null Rule out null Supported by null Colonoscopy null Image studies null Symptoms null Diet null Other Describe null Abscess null Yes null No null Perforation null Yes null No null On a high fiber diet null Yes null No null Describe null Active null History of null Rule out null Supported by null Symptoms null Passing of stones null ERCP null HIDA Scan null MRI null Treatment history null Other Describe null Describe null Active null History of null Rule out null Supported by null Symptoms null Gastric emptying tests null Medications null History null Other Describe null Describe null Active null History of null Rule out null Supported by null Heartburn / Dyspepsia null Regurgitation null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical findings null Lab studies null Other Describe null Type null A null B null C null Describe null Acute null Chronic null Cirrhosis null Yes null No null Hepatocellular Carcinoma null Yes null No null Describe null Active null History of null Rule out null Supported by null Colonoscopy null Symptoms null Physical Findings null Medications null Other Describe null Describe null Ulcerative Colitis null Crohn’s Disease null Other null On a specific diet null Yes null No null Describe null Active null History of null Rule out null Supported by null Symptoms null Lab studies null ERCP null Alcoholism null Use of certain medications null MRI null Family history null Other Describe null Recurrent episodes null Yes - Chronic null No null on a specific diet null Yes null No null Describe null Active null History of null Rule out null Supported by null Endoscopic findings null Culture null Symptoms null Medications null Other Describe null Describe null Esophageal null Gastric null Duodenal null Other Describe null Positive culture for Heliobactria Pylori null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null History of blood in stool null Yes null No null History of black stools null Yes null No null History of Heartburn / Dyspepsia null Yes Describe null Occasionally null Chronic null No null History of Vomiting or Regurgitation null Yes Describe null Blood null Bile null Coffee grounds null Other Describe null No null History of pain after eating null Yes Describe null Right upper quadrant null Epigastric null Left upper quadrant null Right lower quadrant null Left lower quadrant null No null History of Jaundice null Yes null No null Do you follow a special diet? null Yes null No null Do you have frequent abnormal abdominal pain? null Yes null No null Do you have intermittent nausea or vomiting? null Yes null No null Do you have trouble with constipation? null Yes null No null Does diarrhea limit your ability to get out of the room or socially? null Yes null No null Do you see blood in your urine? null Yes null No null Do you have Frequent Stomach Pain null Yes null No null No null levelTwoSingleSelect Bowel Movements null Normal null Abnormal If abnormal null Constipation If Constipation null Acute null Chronic null Diarrhea If Diarrhea null Acute null Chronic null If Diarrhea, history of C Difficile null Yes null No null Bowel Incontinence null levelOneSingleSelect Abdominal Openings null Yes Describe null Ileostomy null Colostomy null Urostomy null PEG null Cystostomy null No null levelOneSingleSelect Rectal Problems null Yes If yes, female null Hemorrhoids null Fissure null Mass null If yes, male null Hemorrhoids null Fissure null Mass null BPH null Prostate mass null No null levelOneSingleSelect Last Bowel Movement null Today null 1-3 days ago null >3 days ago null YesNoMultipleSelect Neuro / Psych Problems (Stroke, Parkinson's disease, Seizures Paraplegia, Depression, Other) null

NEURO-PSYCH

Yes Describe null Active null History of null Rule out null Supported by null Drinking history null Hospitalizations null Physical findings null Lab results null Other Describe null History of Delirium Tremens null Yes null No null History of Psychosis null Yes null No null Describe null Active null History Of null Rule out null Supported by null Progressive weakness null Slurring of speech null Abnormal gait null Difficulty swallowing null EMG null Other Describe null Describe null Active null History of null Rule out null Supported by null History of mood swings null Medication null Other Describe null Describe null Active null History of null Rule out null Supported by null Hospitalization null Image study null Physical findings Physical findings null None null Right arm paralysis null Left arm paralysis null Right leg paralysis null Left leg paralysis null Right hemiparesis null Left hemiparesis null Aphasia null Apraxia null Cranial nerve paralysis null Paraplegia null Quadriplegia null Coma null Sensory findings Sensory findings null None null Numbness right arm null Numbness right leg null Numbness left arm null Numbness left leg null Facial numbness null Paresthesias null Other Describe null Describe null Active null History of null Rule out null Supported by null Physical exam null History null Laboratory testing null Other Describe null Describe null Active null History of null Rule out null Supported by null Affect null Specific symptoms for 6 months or more null Medication null Hospitalization null Other Describe null Describe null Active null History of null Rule out null Supported by null Behavioral changes null Mental testing null MRI null Functional changes null Other Describe null Type of Dementia null Vascular Supported by null History of strokes null Risk factors (Atrial Fibrillation, Diabetes, Hypertension, Hypercholesterolemia, Smoking) null Alzheimer’s disease null Etiology Unknown null Describe null Active null History of null Rule out null Supported by null Symptoms null PHQ 2 / 9 null Use of antidepressant medication null Other Describe null Major null Yes Supported by null PHQ 9 null Hospitalization null Chronic use of antidepressant medication beyond 6 months null Use of ECT null NO null Describe null Active null History of null Rule out null Supported by null Use of recreational drugs null Chronic use of pain medication null History of hospitalization null History outpatient treatment null Withdrawal symptoms null Abnormal affect null Other Describe null History of Psychosis null Yes null No null What drug/s null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical findings null History null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null Symptoms null GAD 7 null Antianxiety medication null Other Describe null Describe null Active null History of null Rule out null Supported by null Physical findings null EMG / Nerve Conduction studies null Hospitalization null Other Describe null Describe null Active null History Of null Rule out null Describe null Left sided null Right sided null Supported by null Physical findings null History null Other Describe null Describe null Active null History Of null Rule out null Supported by null Family history null Chorea movement null Physical findings null Other Describe null Describe null Active null History Of null Rule out null Supported by null Medication null Symptoms null History null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Down’s Syndrome null Psychomotor Retardation null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null Physical findings null Laboratory testing null Medications null Bowel or bladder dysfunction null Hospitalization null Other Describe null Describe null Active null History Of null Rule out null Supported by null Physical findings null Biopsy null EMG’s null History of progressive muscle weakness null Family history null Other Describe null Describe null Active null History Of null Rule out null Supported by null Ptosis null Double vision null Difficulty chewing null Difficulty swallowing null Tensilon test null Medication null Other Describe null Describe null Active null History of null Rule out null Supported by null Physical findings null Gait null Dementia null Affect null Other Describe null Describe null Active null History Of null Rule out null Supported by null Physical findings null EMG / Nerve Conduction studies null Biopsy null Other Describe null Secondary to Diabetes null Yes null No null Describe null Active null History Of null Rule out null Supported by null Symptoms null Medication null History null Other Describe null Describe null Active null History of null Rule out null Supported by null Affect null Specific symptoms for 6 months or more null Medication null Hospitalization null Psychosis null Other Describe null Describe null Active null History of null Rule out null Supported by null History of recurrent seizures null Medications null Laboratory testing null Other Describe null Describe null Active (within 8 months) null History of null Rule out null Supported by null Paresis or paralysis Paresis, paralysis or loss of sensation null None null Paraplegia null Quadriplegia null Anterior Cord Syndrome null Posterior Cord Syndrome null Central Cord Syndrome null Loss of sensation Paresis, paralysis or loss of sensation null None null Paraplegia null Quadriplegia null Anterior Cord Syndrome null Posterior Cord Syndrome null Central Cord Syndrome null Bowel or bladder dysfunction null Hospitalization null Other Describe null Secondary to null Fracture null Dislocation null Compressive Lesion null Describe null Active null History of null Rule out null Supported by null Hospitalization null Image study null Physical findings Physical findings null None null Right arm paralysis null Left arm paralysis null Right leg paralysis null Left leg paralysis null Right hemiparesis null Left hemiparesis null Aphasia null Apraxia null Cranial nerve paralysis null Functional Quadriplegia null Sensory findings Sensory findings null None null Numbness right arm null Numbness right leg null Numbness left arm null Numbness left leg null Facial numbness null Paresthesia’s null Other Describe null Describe null Active null History of null Rule out null Supported by null Hospitalization null Image study null Physical findings Physical findings null None null Right arm paralysis null Left arm paralysis null Right leg paralysis null Left leg paralysis null Right hemiparesis null Left hemiparesis null Aphasia null Apraxia null Cranial nerve paralysis null Paraplegia null Quadriplegia null Coma null Sensory findings Sensory findings null None null Numbness right arm null Numbness right leg null Numbness left arm null Numbness left leg null Facial numbness null Paresthesia's null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Physical exam null Image studies null Other Describe null Describe null Active null History of null Rule out null Supported by null Hospitalization null Image studies null Physical findings Physical findings null None null Coma null Quadriplegia null Paraplegia null Hemiplegia null Monoplegia null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Are you nervous, anxious, feel on the edge or often feel stressed? null Yes null No null Do you worry too much about different things? null Yes null No null Do you feel afraid that something bad might happen? null Yes null No null History of headaches null Yes Symptoms with headaches of null Visual Changes null Auditory changes null Nausea / vomiting null Sensitivity to light / sound null None null No null History of auditory hallucinations null Yes null No null History of visual hallucinations null Yes null No null History of psychotic behavior null Yes null No null History of episodes of delirium null Yes null No null Do you follow a special diet? null Yes null No null Do you have any weakness or deformity in your arms or legs that limits your ability to get around or do what you want to do? null Yes null No null Do you have trouble swallowing your food? null Yes null No null Do you have trouble making people understand you when you speak? null Yes null No null Do you trouble understanding what people say to you? null Yes null No null Do your hands shake? null Yes null No null Do you have convulsions and seizures? null Yes null No null Do you have trouble with your memory? null Yes null No null Do you have trouble finding words? null Yes null No null Do you have trouble sleeping? null Yes null No null Have you lost your appetite null Yes null No null Do you hear voices or see things that other people do not null Yes null No null Do you have highs and lows null Yes null No null Do you ever feel like someone is out to get you null Yes null No null No null levelOneSingleSelect How often do you go out to meet with family or friends null Often null Sometimes null Never null InputBox GPCOG Score null or MMSE Score null yesNoGroup If GPCOG or MMSE is not done, is Patient oriented to person null Yes null No null Patient oriented to place null Yes null No null Patient oriented to time null Yes null No null Recall null Good null Poor null Patient describes recent news event null Yes null Partially null No null levelOneSingleSelect Affect null Normal null Abnormal If abnormal, null Paranoia null Delusional null Disorganized thought null Flat null Manic null Depressed null Other null yesNoPhq Over the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things null Not at all null Several Days null More than half the days null Nearly every day null Feeling down, depressed or hopeless null Not at all null Several Days null More than half the days null Nearly every day null PHQ 2 Score null < 3 3 or more DEPRESSION SCREENING PHQ9 Having little interest or pleasure in doing things? null Not at all null Several null More than half the days null Nearly Every Day null Feeling down, depressed or hopeless at times? null Not at all null Several null More than half the days null Nearly Every Day null Do you have trouble falling or staying asleep, sleeping too much? null Not at all null Several null More than half the days null Nearly Every Day null Do you feeling tired or having little energy? null Not at all null Several null More than half the days null Nearly Every Day null Do you have a poor appetite or overeating? null Not at all null Several null More than half the days null Nearly Every Day null Feeling bad about yourself or that you are a failure or have let yourself or your family down? null Not at all null Several null More than half the days null Nearly Every Day null Trouble concentrating on things, such as reading the newspaper or watching TV? null Not at all null Several null More than half the days null Nearly Every Day null Moving or speaking so slowly that other people have noticed. Or opposite-being fidgety or restless that you have been moving around a lot more than usual? null Not at all null Several null More than half the days null Nearly Every Day null Thoughts that you would be better off dead, or hurting yourself? null Not at all null Several null More than half the days null Nearly Every Day null PHQ 9 Score undefined levelOneSingleSelect Speech null Normal null Slurred null Aphasic null Apraxia null levelOneSingleSelect Finger to Nose null Normal null Abnormal If abnormal null Left null Right null Both null levelOneSingleSelect Heel (Shin) to Toe null Normal null Abnormal If abnormal null Left null Right null Both null levelOneSingleSelect Thumb to Finger Tips null Normal null Abnormal If abnormal null Left null Right null Both null levelOneSingleSelect Sitting to Standing null Normal null Needs Assistance null Unable null levelOneSingleSelect Facial / Extremity Movement null Motor Tic null Vocal Tic null Benign (Essential Tremor) null Intention Tremor null Non-Intention (Pill rolling) Tremor null Rigidity null Spasticity null Chorea Movement null Cog wheeling null Normal null levelOneSingleSelect Gait null Normal null Limp null Wide based null Abductor lurch null Paretic null Shuffling null Ataxic null Other (Findings may also apply to Musculoskeletal diagnoses) null YesNoMultipleSelect Genitourinary Problems (Overactive Bladder, Urinary Incontinence Stress Incontinence, Benign Prostatic Hypertrophy, Others) null

GENITOURINARY

Yes Describe null Active null History of null Rule out null Supported by null Lab tests null Calculated GFR null Hospitalization null Other Describe null Etiology null Describe null Active null History of null Rule out null Supported by null Physical exam null Symptoms null Lab test null Biopsy null Medication null Hospitalization null Other Describe null Describe null Active null History of null Rule out null Supported by null Lab tests null Calculated GFR X 3 null Other Describe null What stage null 1 [GFR > 89] null 2 [GFR 60-89] null 3 [GFR 30-59] null 4 [GFR15-29] null 5 [GFR <15] null Secondary to Diabetes null Yes null No null Secondary to Hypertension null Yes null No null Describe null Active null History of null Rule out null Supported by null Lab tests null Calculated GFR X 3 null Symptoms null Other Describe null Patient on dialysis null Yes null No null On a special diet null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null Symptoms null Cultures null Laboratory results null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Type null Urate null Calcium Oxalate null Magnesium null Other null Describe null Active null History of null Rule out null Supported by null Medical history null Lab tests null Imaging studies null Biopsy null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Related to stress null Yes Related to null Dribbling null Urgency null Other null No null Describe null Daily null Few times a week null Less than once a week null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null History of frequency null Yes null 3x / day null 4x / day null 5x / day null >5x / day null No null History of Nocturia null Yes null 1x / night null 2x / night null 3x / night null >=4x / night null No null History of Hesitancy null Yes null No null Do you have trouble urinating? null Yes null No null Do you ever have blood in your urine? null Yes null No null Do you have any weakness or deformity in your arms or legs that limits your ability to get around or do what you want to do? null Yes null No null Do you have trouble holding your urine? null Yes null No null Do you trouble getting to the bathroom on time? null Yes null No null Do you ever have pain or burning during urination? null Yes null No null Do you ever wear pads or diapers? null Yes null No null Do you have a vaginal discharge? null Yes null No null Do you have vaginal bleeding? null Yes null No null No null YesNoMultipleSelect Musculoskeletal Problems (Spinal Stenosis, Rheumatoid Arthritis, Gout, Osteoporosis, Others) null

MUSCULOSKELETAL

Yes Describe null Active null History of null Rule out null Supported by null Physical Findings null Lab tests null Biopsy null Image studies null Other Describe null Describe null SLE(Lupus) null Scleroderma null Dermatomyositis null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical Findings null Image studies null Medications null Other Describe null Normal bladder and bowel function null Yes null No null Site of disease null Cervical null Thoracic null Lumbar null Lumbosacral null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Traumatic null Pathological null Describe null Shoulder null Arm null Forearm null Wrist null Hand null Femoral Shaft null Tibia null Fibula null Ankle null Foot null Current (within 12 weeks) null Yes null No null Describe fracture/s null Describe null Active null History of null Rule out null Supported by null History of attacks in Foot null Lab tests null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical Findings null Image studies null Other Describe null Which joints null Describe null Active null History of null Rule out null Supported by null Hospitalization null Image studies null Cultures null Medications null Other Describe null Describe null Active null History of null Rule out null Supported by null Dexa scan null Medications null Imaging studies null Symptoms null Fracture history null Other Describe null Describe null Active null History of null Rule out null Supported by null Hospitalization null Image studies null Cultures null Medications null Other Describe null Which joint/s null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical findings null Lab tests null Image Studies null Other Describe null Which joints null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical Findings null Image studies null Medications null Other Describe null Normal bladder and bowel function null Yes null No null Describe null Active null History of null Rule out null Supported by null Labs null Medications null History null other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null History / Finding of non- extremity Fracture null Yes Describe null Traumatic null Pathological null Describe null Face null Face null Rib null Pelvis null Other null Current (within 12 weeks) null Yes null No null Describe fracture/s null No null History / Finding of Hip Fracture / Dislocation null Yes Describe null Active (within 16 weeks) null History of null Rule out null Supported by null Hospitalization null Image studies null Surgery null Describe null Traumatic null Pathological null Describe null Right null Left null No null History / Finding of Vertebral Fracture null Yes Describe null Active (within 12 weeks) null History of null Rule out null Supported by null Hospitalization null Image studies null Surgery null Describe null Traumatic null Pathological null Spinal Cord Injury null Yes null No null Describe vertebrae/s and fracture type null No null Do you have any swelling of your joints? null Yes null No null Do you experience stiffness in the morning or during the day? null Yes null No null Do you have pain in your joints? null Yes null No null Do you have a problem straightening any joints? null Yes null No null Does pain and or swelling in your joints limit your activities? null Yes null No null Have you broken bones(fractures) in any parts of your body? null Yes null No null Do you have constant pain in your bones? null Yes null No null Have you had an amputation? null Yes null No null No null YesNoMultipleSelect Integument Problems (Eczema, Psoriasis, Dermatitis, Urticaria, Other) null

INTEGUMENT

Yes Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null What type null Contact null Stasis null Drug induced null Disease Induced null Unspecified null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null History of Psoriatic Arthritis null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Etiology null Pressure null Venous Stasis null Peripheral Vascular Disease null Disease Induced null Diabetic Vasculitis null Diabetic Neuropathy null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Type null Acute null Chronic null Etiology null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Etiology null Surgical null Traumatic null Burn null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Do you have ulcers or wounds that require dressings? null Yes null No null Do you have a chronic skin condition? null Yes null No null Does your skin problem require the use of chronic medication, cream or ointment? null Yes null No null Do you get pains inyour legs when you walk that make you stop to get relief? null Yes null No null Do you have skin breakdown or ulcers around your ankles? null Yes null No null No null YesNoMultipleSelect Endocrine Problems null

ENDOCRINE

Yes Describe null Active null History of null Rule out null Supported by null Decreased GFR null Albuminuria null Elevated BUN/Creatinine null Dialysis null Other Describe null Patient on ACE or ARB null Yes null No null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Is patient on a statin null Yes null No null Is patient on an aspirin null Yes null No null Describe null Active null History of null Rule out null Supported by null Physical exam null Lab tests null Suppression Test null Other Describe null Describe null Active null History of null Rule out null Supported by null Symptoms null Physical findings null Lab tests null Medications null Other Describe null Type null Type 1 null Type 2 null Gestational null Most recent Hb A1C, value null And Date null Met with a nurse or dietician for diabetic education null Yes null No null Met with a diabetic educator null Yes Treatment includes null Diet null Oral hypoglycemic agent null Insulin null Exercise null Weight loss null No null Describe null Active null History of null Rule out null Supported by null Funduscopic exam null Vison loss null Laser Therapy null Retinal Injections null Surgical procedure null Other Describe null Patient sees Ophthalmologist null Occasionally null Once a year null Twice a year null >Twice a year null Describe null Active null History of null Rule out null Supported by null History Chronic Kidney Disease null History Vitamin D Deficiency null History Celiac Disease null Malabsorption null Bariatric Surgery null Lab tests null History of kidney stones null History of Fractures null Imaging studies null Fatigue null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Is patient on Ace or ARB null Yes null No null Describe null Active null History of null Rule out null Supported by null Rapid Heart Beat null Nervousness null Weight Loss null Heat Intolerance null Tremor null Lab Data null History of treatment for Hyperthyroidism null Hyper Reflexes null Other Describe null Describe null Active null History of null Rule out null Supported by null Weight gain null Fatigue null Hair changes null Depression null Treatment for hypothyroidism null Lab data null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Type null Urate null Calcium Oxalate null Magnesium null Other null Describe null Active null History of null Rule out null Supported by null Physical exam null Skin lesions null Foot deformity null Surgical procedures null Other Describe null Patient sees Podiatrist null Yes How often null Once a year null Twice a year null Quarterly null No null Describe null Active null History of null Rule out null Supported by null Physical exam null Vascular studies null Skin lesions null Foot deformity null Surgical procedures null Intermittent claudication null Other Describe null Patient sees Podiatrist null Yes How often null Once a year null Twice a year null Quarterly null No null Describe null Active null History of null Rule out null Supported by null Lab tests null History of kidney stones null History of Fractures null Imaging studies null Fatigue null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Do you periodically experience shakiness, lightheadedness, sweating, confusion, or blurred vision? null Yes null No null Do you often feel thirsty? null Yes null No null Do you have numbness or burning in your legs or feet? null Yes null No null Do you get pains in your leg or feet when you walk? null Yes null No null Do you get ulcers on your legs or feet? null Yes null No null Do you feel sluggish? null Yes null No null Do you sweat a lot or constantly feel hot? null Yes null No null Have you been told your kidneys are not working right, failing or shutting down? null Yes null No null Have you ever had dialysis? null Yes null No null Is your skin itchy? null Yes null No null Do you test your blood sugar? null Yes null No null No null levelOneSingleSelect Have you lost weight in the past 6 months? null None null 5lbs null 10lbs null 15lbs null More than 15lbs null 10% of your weight (calculated by assessor) null YesNoMultipleSelect Hematology / Immunology / Infection Disease Problems (Anemia, easy bruising or abnormal bleeding Thrombocytopenia , Other) null

HEMATOLOGY / IMMUNOLOGY / INFECTIOUS DISEASE

Yes Describe null Active null History of null Rule out null Supported by null Symptoms null Physical findings null History of opportunistic infections null Medications null Other Describe null Is patient currently under treatment null Yes Where null No null Describe null Active null History of null Rule out null Supported by null Lab tests null Symptoms null History of blood transfusion null Other Describe null Etiology null Iron deficiency null Pernicious null Kidney disease null Hemolysis null Aplastic null Chemotherapy null Blood loss null Chronic Disease null Folate Deficiency null Other Describe null If yes, Patient on null Iron null B 12 null Folic Acid null Blood Transfusions null Other Describe null Describe null Active null History of null Rule out null Supported by null Positive lab test null Symptoms null Hospitalization null Other Describe null Describe null Active null History of null Rule out null Supported by null Cultures null Hospitalization null Medications null Physical findings null Other Describe null Describe null Active null History of null Rule out null Supported by null Lab tests null Symptoms null Medications null Other Describe null Viral load null C4 null Patient currently symptomatic null Yes null No null Is patient currently under active treatment null Yes null No null Describe null Active null History of null Rule out null Supported by null Rash null Symptoms null Other Describe null Describe null Active null History of null Rule out null Supported by null Cultures null Hospitalization null Medications null Physical findings null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Etiology null History of Opportunistic Infection null Yes null No null Describe null Active null History of Remission null Rule out null Supported by null Symptoms null Lab tests null Other Describe null Type null Describe null Active null History of null Rule out null Supported by null Symptoms null Lab tests null Other Describe null Type null Describe null Active null History of null Rule out null Supported by null Symptoms null Lab tests null Other Describe null Describe null Active null History of null Rule out null Supported by null Blood Cultures null Other cultures null Symptoms null Hospitalization null Unstable vital signs null Other Describe null Describe null Active null History of null Rule out null Supported by null Family history null Symptoms null History of infections null Hospitalizations null Other Describe null Describe null Active null History of null Rule out null Supported by null Family history null Lab test null Other Describe null Describe null Active null History of null Rule out null Supported by null Family history null Symptoms null Lab tests null History of infections null Other Describe null Describe null Active null History of null Rule out null Supported by null Lab tests null Physical findings null History null Other Describe null Etiology null Describe null Active null History of active TB null TB Infection (positive PPD) null Rule out active TB null Supported by null History null Medications null Imagining study null Skin test null Symptoms null Positive culture null Other Describe null Has patient been given BCG null Yes null No null Unknown null Has patient been treated for active Tuberculosis null Yes null No null Unknown null Has patient been treated for TB Infection null Yes null No null Unknown null Describe null Active null History of null Rule out null Supported by null Labs null Medications null History null Other Describe null Describe null Active null History of null Rule out null Supported by null History null Symptoms null Physical Findings null Medications null Test results null Image studies null Biopsy null DME null Other Describe null Other null Easy bruising or abnormal bleeding null Yes null No null Long term anticoagulation use null Yes Describe null Aspirin null Coumadin null Thrombin Inhibitors (Pradaxa) null Plavix null Factor Xa Inhibitors (Xarelto, Eliquis) null Other Describe null No null No null yesNoLevelThree CANCER Diagnosis of Cancer null Yes Describe null Active null History of null Rule out null Supported by null Physical findings null Hospitalization null Treatments null Lab tests null Imaging studies null Surgery null Biopsy null Other Describe null Type null Brain null Head null Neck null Breast null Lung null Esophagus null Stomach null Liver null Pancreas null Colon null Rectum null Kidney null Bladder null Ovaries null Uterus null Prostate null Bone null Blood null Lymph Nodes null Skin null Other Describe null Specific type/s null Stage or Classification specific to the cancer null Active treatment null Yes Active treatment null Chemotherapy null Radiation null Stem Cell null Bone Marrow null Surgery null Immune System null Other Describe null Side effects null Nausea null Vomiting null Diarrhea null Anemia null Neutropenia null Thrombocytopenia null Weakness null Loss of appetite null Other Describe null No null History / Finding of Metastasis null Yes Location null To Cancer, history / finding of Cachexia null Yes null No null No null Do you see a specialist? null Yes Provider null No null No null yesNoPain InputBox Blood Pressure null Pulse null Respiratory Rate null Temp null Pulse Oximetry null Pain Scale /10 null BMI yesNo Constitutional General appearance: null Normal null Abnormal null yesNo Head and Face Examination of head and face: null Normal null Abnormal null Palpation of the face and sinuses: null Normal null Abnormal null yesNo Eyes Inspection of conjunctiva and lids: null Normal null Abnormal null Examination of pupils and irises: null Normal null Abnormal null yesNo Ears, Nose, Mouth and Throat External Inspection of ears and nose: null Normal null Abnormal null Otoscopic examination: null Normal null Abnormal null Assessment of hearing: null Normal null Abnormal null Inspection of nasal mucosa, septum and trubinates: null Normal null Abnormal null Inspection of lips, teeth and gums: null Normal null Abnormal null Examination of oropharynx: null Normal null Abnormal null yesNo Neck Examination of neck: null Normal null Abnormal null Examination of thyroid: null Normal null Abnormal null yesNo Pulmonary Assessment of respiratory effort: null Normal null Abnormal null Percussion of chest: null Normal null Abnormal null Palpation of chest: null Normal null Abnormal null Auscultation of lungs: null Normal null Abnormal null yesNo Cardiovascular Palpation of heart: null Normal null Abnormal null Auscultation of heart: null Normal null Abnormal null Carotid Arteries: null Normal null Abnormal null Abdominal Aorta: null Normal null Abnormal null Pedal Pulses: null Normal null Abnormal null Examination of Arterial Pulses: null Normal null Abnormal null Examination of Edema / Varicosities: null Normal null Abnormal null yesNo Lymphatic Palpation of cervical nodes (neck) null Normal null Abnormal null Palpation of preauricular nodes (in front of the ears) null Normal null Abnormal null Palpation of Submandibular nodes (under jaw line/chin) null Normal null Abnormal null yesNo Musculoskeletal Examination of gait and station: null Normal null Abnormal null Inspection/palpation of digits and nails: null Normal null Abnormal null Inspection/palpation of joints, bones and muscles: null Normal null Abnormal null Assessment of range of motion: null Normal null Abnormal null Assessment of stability: null Normal null Abnormal null Assessment of muscle strength/tone: null Normal null Abnormal null yesNo Skin Inspection of skin and subcutaneous tissue: null Normal null Abnormal null Palpation of skin and subcutaneous tissue: null Normal null Abnormal null yesNo Neurologic Indicate specific cranial nerve tested null Normal null Abnormal null Indicate cranial nerve deficits found null Normal null Abnormal null Romberg Test null Normal null Abnormal null Examination of reflexes: null Normal null Abnormal null Examination of sensation: null Normal null Abnormal null Coordination: null Normal null Abnormal null yesNo Diabetes Foot Exam: null Normal null Abnormal null yesNo Psychiatric Description of patient's judgement / insight: null Normal null Abnormal null Orientation of person, place and time: null Normal null Abnormal null Recent and remote memory: null Normal null Abnormal null Mood and affect: null Normal null Abnormal null screening Screening Name Member Eligible Status Barcode Confirm Barcode Screening Completed Exam Date Screening Result Diagnosis Comments DIGITAL_RETINAL_EXAM No Select null null HBA1C No Select null null MICROALBUMIN No Select null null FOBT Yes Select null null DEXA N/A Select null null PAD No Select null null Peak Flow Meter No Select null null miniCog Word List Version null Person’s Answers null Word Recal null Clock Draw null Total Score null levelTwoSingleSelect 40. In the past year how many times have you Fallen? null None null Once Do you worry about falling or feeling unsteady when standing or walking null Yes null No null Worries about falling or feeling unsteady when standing or walking? null Yes null No null Did you have a fracture in past 6 months? null Yes Was it due to fall? null Yes null No null Are you on osteoporosis med? null Yes null No null No null Twice Do you worry about falling or feeling unsteady when standing or walking null Yes null No null Worries about falling or feeling unsteady when standing or walking? null Yes null No null Did you have a fracture in past 6 months? null Yes Was it due to fall? null Yes null No null Are you on osteoporosis med? null Yes null No null No null Three times Do you worry about falling or feeling unsteady when standing or walking null Yes null No null Worries about falling or feeling unsteady when standing or walking? null Yes null No null Did you have a fracture in past 6 months? null Yes Was it due to fall? null Yes null No null Are you on osteoporosis med? null Yes null No null No null More than three times Do you worry about falling or feeling unsteady when standing or walking null Yes null No null Worries about falling or feeling unsteady when standing or walking? null Yes null No null Did you have a fracture in past 6 months? null Yes Was it due to fall? null Yes null No null Are you on osteoporosis med? null Yes null No null No null yesNo 41. Home Safety a. Do you have obstacles in the house, loose small rugs or objects on the floor that could cause tripping? null Yes null No null b. Do you have electrical cords running across floors, in doorways or under a rugs? null Yes null No null c. Do you have no slip mats on the shower floor or bath tub? null Yes null No null d. Do have adequate lighting in hallways and on the stairs? null Yes null No null e. Do you have handrails on staircases? null Yes null No null f. Is your hot water heater set for a maximum of 120 degrees? null Yes null No null g. Do you have smoke detectors on each level of the house and in all sleeping a rooms? null Yes null No null h. Do you have carbon Monoxide detectors on each level of the house? null Yes null No null i. Have used established an escape route in the event of fire? null Yes null No null InputBox 42. Are there things about yourself you wish you could change or improve? null InputBox 43. Is there anything that you could do to improve your quality of life? null levelOneSingleSelect 44. Have you ever physically or felt emotionally abused by someone null Yes null No null levelOneSingleSelect 45. Feeling like harming others or yourself null Yes Who do you feel like harming? null Do you feel like this at this momen? null Are you in a safe place? null Would you like me to assist you to call 911? null No null levelOneSingleSelect 46. Are you afraid of anyone or is anyone hurting you? null Yes Who are you afraid of? Are you afraid at this moment? null Who is hurting you? Are you being hurt at this moment? null Are you in a safe place? null Would you like me to assist you to call 911? null No null icd-10 ICD 10 ICD-10 Description DX Assmt Monitor & Eval Tx Plan summary Assessors Comments null Time exam Started null Time exam finished null Date of Service/Evaluation null Member informed of acknowledgement null