Medical Report: 24-Year-Old Iraqi Male, Detainee, Abu Ghraib Prison, Camp 4, Baghdad, Iraq re: Fractured Nose and Eye Socket

1 . REPORTING MTF -2. MTF LOCATION
ADMISSION AND CODING INFORMATION
1 2 F7-31 4 5 I6 7 8
(State or Country
A _0, DI --eCode.) For use of this form, see AR 40-400; the proponent agency is OTSG
3 . REGISTER NUMBER
NAME (Last, First, Middle Initial)
4. PAY GRADE 5. SEX
9 10 11
I r 13 1 15 N)(6) -,4 18
12 144
.._.... 16 17
i
6 . DATE OF BIRTH (YVVYMMD17) 7.
AGE AT ADMISSION 8.
RACE 9. ETHNIC
RELIGION
19 20 21 _1-22 .1 23 24 I 25 i 26 27 1 28 I 29 I 30 ' 31 I BACK-
I

I -1 (....,, GRO UN D
I
1 I g._ 1 (.0 I u¦ 2.-1 V
10. LENGTH OF SERVICE ETS
11. FMP ----)
12.
SOCIAL SECURITY NUMBER
32 33 I 34
35 6
37 i 38 39 40
I
41 42 143 44
;, ; :---CAM
_____I
_
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF
BRANCH 1 CORPS
( I) CO '-' 4fr
ADMISSION
0 Pc 46
z..4 1 (..-1-4 0 ti Pc
L , .
14. FLYING STATUS 15. BENEFICIARY CATEGORY
52_, 16. ZIP CODE OF RESIDENCE
47 48 49 1 50 51

53 1-T1 55 56 57 58
I 59 60 61 1
1‘.. V¦ -1
I I
17. UNIT LOCATION (Stare or 18. MOS 19. I
TRAUMA PREY. ADMISSION
Country Code)
62 63 64 I
65 66 67 I 68 69 70 71 i YEAR 1.,
'--'2--"
I
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION

72 U¦..N.) \-.
ADDRESS OF EMERGENCY ADDRESSEE

.C, Lr) I (Include Z1P Code)
u.-IN) N.-
NA , .1. • • • . • .. • .
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION
/V YMMOD1
73 74
75 76 177 78 79 180 I 81 182 83 84
85 86
.
H.. . ____.
I OI 0-)I /
24. CLINIC SVC - ADMITTING 0 I 0 SI
25. MTF TRANSFERRED FROM
26. DATE THIS ADMISSION
(Y YM M 0 D1
87 88 89 E 90
91 92 . 93 1 94 95 96
97 1 98 1 99 100 101 102
.S.L c) b .
L..._ , 01---- I O TC 3 _
27. LOCATION OF OCCURRENCE 28. MU OF INITIAL ADMISSION
29. DATE INITIAL ADMISSION (Y YMMODI
-1 (Battle Casualty Only)
103 104 I 105 , 1067107 ---

1 108 109 110 1 111 ii 112 1.0041111611Mal
1
I
I
I I
I
0 1 Th 0 OS
FOR LOCAL USE
D x q a-7- o 16.01\
(657 (0 )(0-
p roc, ( -1 Tr a() )-y _ el
ADMITTING OFFICER
(Si a ture, as required)
SIGNATURE OF ADMITTING CLEE07-
(019-z-! 1,.16) -7-
MEDCOM - 208414It
DOD-034415
I.

ABU GHARAIS MEDICAL TRANSFER REQUEST FORM
DATE OF REQUEST: 0Z OeT 03
REQUESTOR:
(1a)(b)-z_ (6) t5) -z_

-
ISN #:
COMPOUND: 4
PRIORITY: 45107
LITTER (CIRCLE)
DESCRIPITIQN OF INJURIES:

Gtr. idfl
NUMBER OF MEDICAL PERSONNEL ACCOMPANYING:
DATE OF TRANSFER:
TIME OF TRANSFER:
DESTINATION:
POC AT DESTINATION:
ANTICIPATED LENGTH OF TRANSFER:
EQUIPMENT REQUESTS:

NOTE: COORIDINATION IS ALSO REQUIRED THROUGH MOVEMENT CONTROL FOR A TRIP TICKET.
MEDCOM - 20842
(6)a0)-z_
ci A9 K5-
eghj`
el) 4.15 4(4, /eW C« 41-4.%
ey g4r 4 _76,"c
kJ/ /1,^014,1 cYl•
Co 71,-4 Z-e/
/ )ry--
ol),,
0,77/
(10)1 6)
J;s Lc9,/-5-----
1"-AekC L'"(-C2^
lec
b_e,v1,
e cgy‘
(
,1,1.5Rx°1-Cr Ta ,/6¦4‘e L5"
k
v. 5
L i s ()11)-14
MEDCOM - 20843
11111111

(
_c
0 /0
,c7 6E4 J{ Ch /
"--t
(/— -1 1/1.,44

/ / 5/ 0 3 A
/2
i. Act
3 a72,--graieNe
ix es
c:4440*-
5 . 6D
ALA ,;
o 21).
p.
-TY
1+.
A .
00)(G)—
011110
c6)60-
)1-01111111111
1 110 /3,40?
MEDCOM - 20844

AMP& 401-

(
CetJ 1.•
4149 2 '4

coto-1
1,9 p,
Gain: 72 dB

dior
eq: 12.5 MHz

03/09D

Range: 35 mmD

Gamma: lin!!!!"1111:

TGC: vit/ret Reject:off

T.Avg: offD1111111111;

Vel: 1550 m/s LI.

+ MENTOR
31 2° OPHTHALMICS

11.11/1(6)(0-1 6)'
AM_----P-M-1

OMNI "6) 4
1./
reLtA-r11441--1— --771;11A4.1A/Late-
r.r.415/i /4'4-ti(. y/Ict6:
--,e-Y-ct,-,A-;i4 -L0(. ophad4-11
-146,4e , 14.'iw-0.1x C62,Leie4frvtz1/44-1)-------.- • /ethlayLetu .c?cbct_ckinA.(4A,t
MEDCOM - 20845

DOD-034419

INPATIENT TREATMENT RECORD COVER SHEET
For use of this form, see AR 40.400; the proponent agency is OTSG
GRADE

ADMISSION REMARKS
6,0(6)-4/
ADMISSION

FMP 12.4SsN4 13.4ORGANIZATION 14.4WARD
Ci 4 4...) -at
154FLYING 11,3 1-
16.4 ID.4BRANCHICORPS 19.4UICIZIP

STATUS4 0564 20.4TYPE CASE
BEN
Ktl—b
4

214SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22.4HOURS OF 23.4CLINIC SERVICE ADMISSION

244NAME/RELATIONSHIP OF EM GENCY ADDRESSEE
25.4TYPE DISPOSITION
26.4DATE OF OISPOSITION

ay\ \I, -sz /4Oc.X . iPt3
27a.4ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code) 27b.4TELEPHONE NO. 284DATE OF THIS ADMITTING OFFICER4
ADMISSION

(6)16)-z
20.4.)' b•Cs.'")
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
30.` DATE
DATE OF INTIAL 32.4UNITS OF MOLE ADMISSION COMPONENT TRANSFUSED

1-1 Check if Continued on RIVW3S
CAUSE OF INJURY
34.4OIAGNOSES/OPERATIONS ANO SPECIAL PROCEDURES
`B\atoa.rka, pki la (.‘---of CgS9u 0
35. Total Days This Facility
36. ABSENT SICK DAYS TotalDay; All Facilites OTHER DAYS CONY. LVICOOP CARE DAYS SUPPLEMENTAL CARE DAYS 0 BED DAYS TOTAL SICK GAYS
ABSENT SICK DAYS b.4OTHER DAYS CONY. LYICOOP CARE DAYS SUPPLEMENTAL CARE DAYS 6E3 DAYS4 1.4TOTAL SICK DAYS
SIGN DA LOC(0)-z- 046)-­z_ EDITION OF 1 SIGNATURE OF PAO OR MEDICAL RECORDS OFFICER Y"--G 76 IS OBSOL 6)(6) -z-- USAPPC V1.10

MEDCOM - 20846

DOD-034420

MEDICAL RECORD I
ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY, CHIEF COMPLAINT, AND CONDITION ON ADMISSION
(Enter date of admission)

see 3Foco

PHYSICAL EXAMINATION
PROGRESS
(Enter date of discharge and final diagnosis)

SIGNATURE OF PHYSICIAN DATE4 I IDENTIFICATION NO. ORGANIZATION
PATIENT'S IDENTIFICATION (For typed or written entries give Name last, first, middle; grade; date; hospital or medical facility) REGISTER NO.4 I WARD NO
ABBREVIATED MEDICAL RECORD Standard Form 539
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR 141 CFR1201-45.505 OCTOBER 1975 USAPPC V1.00
MEDCOM - 20847

DOD-034421

(10(6) -q
_......

1,,,, AU I tufniztu I-UH LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry/
C OM -4
Aleir an /raft pethalf k(he ,efeoltd 07/71
.Ah pe igonM hArk9e ¦416 'hilt AirAmo 7$ ht,t .'le-e , t • Elrim meek*" et lihhe c,v .21"Ceil

.A 0.414111/ eilaitther, /arc ffeod14,exr dr Il ektot,t leir calikAPee ONO *kV' 'the, 77 Of erar 1
.preint. WWI dew Pt pitted In.goofifre, 4491ow i .0k4/1
.4 0.1141111111 PitYlefi. PI0W7/0" a edato of cowl oitt ecoimif
.Over /le- ,,c hem. /0 dm* //7treRied kane.
.v A 5:61:1- . Aided erro( dix,w Ardapt V'

.2Wr plizfivtir.-* iiiiiieez- dkicon4. .'.if nrimaAe at iithee a_ Attoliwydent.iie--orteotivii7 infamnah1/0
POO: releAenti.
it!..,L.Ai.a I.1./..._ i 1.

deffd placental- kfehier-Ava0; lais "101D1.W
eze

HOSPITAL OR MEDICAL FACILITY
STATUS
DEPART_ISERVICE RECORDS MA NTAINED AT

( L)6)--2-

SPONSOR'S NAME SSNIID NO.
RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name • les first, middle; ID No or SSIII; Sex; Date of Birth; Rank/Grade.)
I REGISTER NO.
WARD NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600 (REV. 6-97)
Prescribed by GSAIICMR

FIRMR (41 CFR) 201-9.202-1 USAPA V2.00
MEDCOM - 20848

DOD-034422

Cb lb) -

DATE4 SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
,

A A k ' -7 c.-(6)0,)-; Ti 1 0 G,. ,,, Jr
,--v j-e-I if A9 ,-
c Is ___,..,
2,-,-:___.6,)03) - -2-.
r
r

r Vi--
/-

• ,, 6 ,
t: _ -

i..._4s4...4A . vs4• N 0.. -0 044" , 1.1.4(vi, I.._
r4
eij44,.... «4—
pie n(4. p-h., A / rr`I-4 • Gf"" 4

c.. V' 074 ,--. 01 r- J P 1,
-(Iee1)411. d4,-
(2-)4,. ,I4_)4
(444 i J / ) ' t for ,4 p ,
3)47; 14•C A-4` ' ,9-(.„-------J,___
411,4 4Crsj4,44IAA4( )(7)--2_ .,7; Y_4in ,t-, )4--,4.....---.-;..-Pti..» 2 v4 /4y r4. ., A / 4- 3 4f r-ev44.-4.4eV/46 14i 2 /.7-4,--„44(P. r, (4/) 0 1 74,J)/1.9(N-4P./W4Z"4grv\--7, i /J.\ (1-‘/") c4i'v.47 ,U4J c9 P4 ,-/V 4eh'4'7r46-e4e.",, 72)--.5/4,//4(-k-v-\ (--"IY,1 // :--------/--,- t X 4/o I(¦ :.-4i4V-476A e\_J4-1',,71747-- ..ic -, -,-(L2 7/v4did 4.(, )414/),11z. 4 /----4116'‘..../ 4 tk-4r¦ STANDARD FORM 6-071 BACK
/2 in j ,(4116A-, tx,V.L--e 6 /1J MEDCOM - 20849 QA•-COL 6)

DOD-034423
,4AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF ME. CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry/

0 Z. C Cr CI 3 ---• Uor% ,it F 4
'Pt

__Of-a-:.-L
.

o -.P-1 ..eArt.,..„.ts.--e--..„.,, ,....tr,,,..„„..
.A-•.git0 7,,t.-...e eie_-&-a..)-1-2 % 1..__ 1-1‘,..:
U0_)
Lij'A
.'11,2-it.A.4.a.a.Aitife4,1 f•-..-¦A

„,...

(t.)(6) -z

3 OCT O,3

kadeni fel atm -ctatorm claw9ierivh* t-

Air,k mu? hti lati NAM-6frlafr II VI-7. ON MI M C44)1/0/6 4 01) Al LI) .
OD pralkiftit WY',
: I shu ye, tos-,—
z 0
f' '
?,::,,,,,::, ;4

etrelivartr hic
1 %. TIC. 16
atom

HOSPITAL OR MEDICAL FACILITY STATUS4
OFPART.ISERVICE

RECORDS MAINTAINED AT
SPONSOR'S NAME SSNIID NO.4 RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:
(for typed or written entries, give: Name • last firs:, middle; ID No tw SSIV: Sex; Owe al Birth: Rank/Gimlet
REGISTER NO

I WARD NOL6)(6)-r NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

"411111111111ft

STANDARD FORM 600 IREV. 6-97)Prescribed by GSARCMR
Co", 9
FIRMR 141 CFR) 201-9.202-14 USAPA V2 no
MEDCOM -20850

DOD-034424

VC:4t/i,bitix4Atm an rthot vv1-1 '2.--CeNAV÷-3/79)nent. D mac-0.4-16(9 ,4
vLew conroni--%ca
OSAr-
Inaeale-(12--i) peerpo Tr
Sege C9(c/nt- Wrna it7 Ob
6-freturnahc ryytdrika_g4
tvNtiskatpt:5

l'HoF ftafornAhal
vvpitty de. stithhir-othon
co'71C ecierrtN-rftorn 11012.
-to Vt(s)rfni

?taw- A7Amti-­
-dcy
13Vectrire-A57no efanj ?ex
ahs

"Tim
Coorclink -Pr 'FP (ewe Ply

44
MEDCOM - 20851

DOD-034425
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD I
PROGRESS NOTES

DATE
NOTES

03 — n zcs ,C,z) 6-114-7-t.z,b ck_rv,it3 v t y
jr
4-0 0 el/49,..e&ke n4re4

AA-4 h .
(s
c'sek;
I
-
(L)(&)-7_
11-e IC1-14_9'
.dralo /2-r-

srl-k. ii,412,e,v-u..}.J
0
eito CL-1,-;43

(2) r 1 7)/1)11
• Ai f

ood-03 tewo--tO 3 i
51s
sethsuivdt
4°

VA[: (b)C0-1._ nittli&tvr

oatILL's.

Xa/":5-
,i

727,/i/#/ z '/1/
i0( 0 e7/ •
RELATIONSHIP TO SPONSOR
LAST NUMBER
IMI (SSN or Other)

DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY

RECORDS MAINTAINED AT
I
I

PATIENT'S IDENTIFICATION:
(For typed or written entries give: Name - last, first, middle;
REGISTER NO.

ID No or SSN; Sex; Date of Birth; Rank/Gradel WARD NO.
I

PROGRESS NOTES
Medical Record

STANDARD FORM 509 (REV. 5/1999)Prescribed by GSA/ICMR FPMR (41CFR)
101 -11.2030:4 USAPA V1.00

coco -r
MEDCOM - 20852

DOD-034426

(b)lb)-

LAS1116E/D 6,t/ FIRST NA MIDDLE INITIAL ID NUMBER
DATE NOTFS
50c/-10 666 ai/.rwei atx epz-, "á /g/(-0,-1 .//7 g /;"/ 0 c/o aff;t/ atz mi /1 ,ii. _ moo/4,v se c(404E., ,,t/o.fit orkfropax_ w/e­
i/ c;‘',-,Kpz/e/Ae;:o e'kel f,./ W/ Ca. ceoth/-6 : f:A//i K-E-Ofst7w/jte Ai/*(0 eet*/7k/i/, a i d COXAVW h .-667­
4,4
57de3 ----r_.,,,i c. tz4,,,. .7z „ LZ 7r,
-zo eJ • , - - A / i P _,....•.:- "....•
.5'007'0 -.'.4 - / 4.' .._.-/-,-414" - --IIIP,Wil‘ ¦-AraPriligliV (4)(1

( 1-, )0
.._,..,¦4, ,, --ae-6,- AA__
4.1 61(40-3 / 77 Af_teke4-4 fro A-3,4Z--S. c 77-4 e 0-/..._z prrc5-e— 7 ; 69 )6 . 3t-4/
(6)!14.so;
6*2-5 FeA:Nok . 1 -t-l-,, AA-,

¦-;-) c 1 / r-A-7/1-r,-11 ( ',, c. J. :7 --7,--,kt-i---4-4/, // `:1 '
i

0.)16)- 7_7g /7?6/7/Af-•4• '; Tromi,69 045 lei3o -- V5S ) R-fro )4.3, 0(010 vis--fory( 01940(04ND t,t9eyi Aiy)(,)ornimAt
cis 1111 laii41J/ lAtd-litili -1-?) &,eXA ° 66Y1,+) 1 Ili • # ' ' 0
4 4

604(4/01 94102 0.teitit. ) Yi tr/ (,• . •.i A__ Do e ve-vi 6-reakdak 4,64-eot . a-kJ/Lb/act-tip E-ta.pte.ro.(,-vir'(_ i / (oto_
• da t i i i J../ -fr) rvirfm:rtzle. _,,
JO. _e so ,•-•. ti_A2 ...kg.•(Q S OD/
fi)94.2fiAAp ) (pAgi) -fa 4 vy A . , isowls zefaive-17)44 e. ' it4cr,w) er a.avykAyA4str_A_Lck_ PA Q-e °cove OtA S. eclutil) , 1' b s;=:
STANOAV1D FORM 509 (REV. 5/1999) BACK
USAPA V1.00
MEDCOM - 20853

DOD-034427

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD CHRONOLOGICAL RECORD OF mtDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION

(Sign each entry)
,??

Pf-teem por) r rye quie
Vt, IR 5g ginj
Miatcyglit edema
grossly buret e &

ill /tie- 95 Cornea_ teach Kc Ictled

ly1)0 CoQ cv. lnifizatir inOanonahm 02) (6)--
6-)(0-7-
4hil4c Atuanta-. przimithi TM. Pirilave
?kw txunA Ahm pd
klichts\ Aphafin, ICingult
4Pted 401 po

(1.)(.1)) - z_
see uiil i ar /ph& *. om
emotIlitivitt ip

(10 Lb) -
reirdviatspitiorsure/
LTA

HOSPITAL OR MEDICAL FACILITY
STATUS
DEPARLISERVICE

RECORDS MAINTAINED AT
SPONSOR'S NAME
I
SSNIID ND.
RELATIONSHIP TO SPONSOR

PATIENTS IDENTIFICATION:4(for typed or written entries, give: Name- last first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade./
REGISTER NO.
I WARD NO.

40 09) t
I

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600 (REV. 6-97)
Prescribed by GSAIICMR

FIRMR (41 CFR) 201-9.202-14 USAPA V2.110
MEDCOM - 20854

DOD-034428

MEDICAL RECORD PROGRESS NOTES HORIZED FOR LOCAL REPRODUCTION
DATE NOTES
(A)-0-a OfTX7FAIALt 71-0 kn/M/14 09)(0) — 2-

Nu _I aim
$ A .4
fail 4). / *A '
Al/ ita /MA A.A.

(.. Ar
my Al I di I d Al .#.

1.di. I /2.4 t tii r..! IP •

JA *AC ¦
_
(3.)(1.)-1_
a

RELATIONSHIP TO SPONSOR FIRST DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY

PATIENT'S IDENTIFICATION: /For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)
(1,)(10).-/

_.Al 101 171 a _
WOO -'SID NUMBER

(SSN or Other)
RECORDS MAINTAINED AT
REGISTER NO.

WARD NO.
PROGRESS NOTES
Medical Record

STANDARD FORM 509 (REV. 5/1999)
Prestribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 0)
USAPA V1.00

MEDCOM - 20855

DOD-034429

MIDDLE INITIAL ID NUMBERFIRST NAMELAST NAME

NOTES

DATE
vth (/) NKr / 0 I no (0? WriV3thincti? IA 41-..ALL4 A •wad c+ 113 t 1
dINWI
con't votly1 octc_cc nju, cuY119 xd_

cAti2a

A A 11. re as MI h.
IN .•
SS a
.

10 ocl Ia A. .._ Lin A 0 NPIO.-41( 0 of fign -H/Lue¦ Carievilo_e
, 14
• ILI I
. i •. • • :kJ.
• oei

.sib OD ti I ° LO.0,.AP.oft
I

be_ ciastii ricy\ci A.,94.“..06( 6219/e /-(,f,i- (ce4,d,:eff ,o7rizai-arit,/ (pc, 4. P-i- G /c/?oio CO?-/---- a/ ,,--to e6 .(\c/)--60 3 -1 L.' Aod c-Jt 0 oial-ed it 0
i /

I.Ag--( rigrecP ciLy `..13-(An_czkv picrou/ y z - . aciftm
cY1-1-fitist6Oakilq ived. lags 2(-
1i

IVA( 1 11 ).JA1.)
--Ebx
qt-tS frrrth- p

LA AN );(\

NN STANDARD FORM 509 (REV. 5/19‘bitklA3ACK USAP s.y1 .00
MEDCO 20856
-

DOD-034430

LAST NAME
DATE
02)1_6)-2_
Pr /tens•
Araks
ugeivily
R.1ST NAME
MIDDLE (NMAL ID NUMBER
NOTES
splyndor taks, Ints St,/ v)(ailarl pra 19 TM. ety,sfiin &heti/1

ft plata( un tn4tmum mnit4ti 1:64t1-ft) 1.91 h6cPtild (14 wry. Tivta rellArngi F: "tit+ plait pt-d1amn4 R?( (pt-tartgal eviL K)r.x attui1J9 Fix rhvono,[1,
, a ,
. •
%a:WYE= %WA rA dIAA I.! A‘
• N IIP.O! ;UM PO 11.111111 FAMIF. ; • PlimAraiv ilia,.
/ /
th pnot hopixf
61,1104/
Anitc i50

Rite& alp 1,144 /4115 U bid cptue dit- 5 minukg apt_Mtalivvi TCS 0-* N)117 btamix
co - -z_
hedilvik
Ph-, tammiti ¦ a. 1 0.)(6) -Z-
)-

PI 1D.L'\°)

/.. MIV
A• f_
r (r
(b)L42) -2-

_IOC, 1 _a A:
tilt II if 1 lYV

AwarA' '0,41)- z_
IPM6SZAM: &WIEN Irriviitaff:'1101Cil•INSIUM/IgilifiC
07)(0 -'71
61a-ft

STANDARD FORM 509 (REV. 5/1999) BACK
MC

USAPA V1.00
MEDCOM - 20857

DOD-034431

-ftegi
-

Pliwt—aamiroibe& ce .f 11 Per-ife9ftw-70--Zosii* Ato2worr'llr
/d mc ti

114711 11149MONE
,Oire 474s-prre-
(6)(6) -
at° lc TM
TD 2( TtAJK--
7fil:f"r Pk.

MEDCOM - 20858

DOD-034432

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
1 % 03 PI-on /1/1/11T 1 A{onei 752 melodl
44W, Alar7 Xalit&tnrp mal f)m.ftwx,
anti- ionnialoy -

&di),
liac hem crenl-to 0-whan hopIN x.
2- Ail/awn/14
crtwly
f &IA Ow rehfilleir reract-(// medial
viahfied k%/ ',cavity he Awl Tip ///rei csyf f denci are 10 pram iv At/11We firs vekai-ed 45 pi' is leefnlw aivi unu-e hu appra•ritirs e oslz-,bgt
--6ts he is apiaii ((kinchoidi Had) •i(te. if-a-eme-e it he timaeni,Ic ay. 4,se,mbir l /14Gt
lea fr *Mine, 1.11 • (rl-11Wld
erifter--
„,.
otralvi4 /I-lotwbk Mi A 1-,ate-/at/6671'4We Alva) t-cidatopw opletidigt et crirnikr 93.6/frzx in thilrivi crettir-mat reste(t-m /70 re4 Ighips availthe d94--0-13-601-

CbX6)-
HOSPITAL OR MEDICAL FACILITY
STATUS

ECORDS MAINTAINED AT
SPONSOR'S NAME
SSW) NO.4
RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION:
(for typed or wince entries, give: Name - lest first, middle; ID No or MN; Ser, Date of Blab; Rank/Gradel
REGISTER NO.
WARD NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE
4riir %1,0%, 1 I
‘ No\
Medical Record

STANDARD FORM 600 (REV. 6.97)
CL,)(b) et Prescribed by GSAIICMR FIRMR 141 CFR) 201-9.202-1 USAPA V2.130
MEDCOM - 20859

DOD-034433
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
ritieav z-/44-421 Pocraft---4ce1rozzez getr.s, fie,/ Asrax-(.41-40/ Re-xviz. Quee4i7. cow-
cla)1b)-1

wo3 Titzetv c im7rnat7 frr bevite-s % -7 AO &WAWA/ atiPts7arifi-Vg &1°-/My 101/4'D ‘fria- G4-47,rs D4 M^k 'Ryerx__Om-n4ovs
STANDARD FORM 600 IREV. 6-97) BACK
USAPA V2.00
MEDCOM - 20860

DOD-034434
'MEDICAL RECORD PROGRESS NOTES AIflH FOR LOCAL REPRODUCTION
DATE
NOTES (b)t o-z. (01G
A
/-
AS
fei _.•
(b)1,6)- z
kAi

SPONSOR'S NAME SPORSDA'S ID MAMA =Yu Ofisri -
DEPARUSTRYICE DOSMAI. OR MEDICAL FACILITY RECORDS AIM/PAINED AT
PANDITS IDEPTIFICATIOR wed or **ea evoiruirr &Kw .hst Ss& mak door iSlt Sq. Dna al Bitk &abrade WARD PD.

PROGRESS NOTES Marcel Record

(6)(6) -L/ STANDARD FORM 599 IRER WIDOW Presrand by SSAYOZI FNAD MOP 101412(ORRIDI
USAPJI
MEDCOM - 20861

DOD-034435

Translation Bates page Medcom 20861:
I refused to have surgery for the right eye. 10/12/2003

DOD-034436

DATE NOTES
‘O_OC.Ten NV() VSZ
cla pat.()
C161
&kik
• TALI&
(Loco- /
C ww11 Cil 1 tv¦ s

qnki -ezscri-Na3
&k_124--1--

•\-) -,i-cy_,Aic . YDS 0 C.b .vcm. Ccsm-k-, C6 atk, , c-1. '+ cm -kr-) Ff_._ c--i-\=,Pc-\­
00-, . - Nmb -NNI.211 CP. C d¦ ?7,1\r"¦QS5 A.AI -TO. ck(----
3 (--V-(=,\ \NIE:=1\ - q\c\‘c•c--.¦ sd¦ ti (5 - cijo\-- ( ,,_7,.Vc&C)\- --mm -9\e c) --:3
%Sf(---- C 11 cs...-i--1C--Ims--Akk6 --\--M. .-vt- \c-,-:::c¦ \ms0-Q ()lb) - i-
f S rest re --k-D X s S L C_ TJX 6; .)zt. ____I ? 15 s-et-4 et.6.
ck\y-, or- 1 rs,-,,,r, N---j-1 Crw¦ --V. .e.)/,--e__*-iS i

(0(.6)-;
10--eirs .n -1 Ter-,-e or-) e, gluJ
(19)? :1), F-•1 --roc-c\

c-S---70 60c0--Gb p (Z=Tr-r-k-v c cam \en\t"-* c-ts--1--N Cwt C^ ocd.acQa. cx-(-43 .(40\ Clo
ck • \(n`cA
\‘r .S1)c Ck-)1V\ \r"

\cNnc-67211-•
MEDCOM - 20862

STANDARD FORM 50900.5118891 ACK
DOD-034437

AUTHORIZED FOR LOCAL REPRODUCTION
' MEDICAL RECORD PROGRESS NOTES
DATE
NOTES
Pr"-Ham t`/a, &filer portm44 /fix brii/#evffmcie A-APD

nc4­fig-smAgotAgiv-ArAcrK Sows, Aiente.s 414711/vA lAinttroAi Ovesafrritts Asneprz Mu-Ritsairr
&brews PD.
Mgr = AmAirmi Zaex 4 lb k-ealt-
/r

le
rd.( Ai r 74144c
Ti
Zfrici^ 161A14 14,0 Nib. niebvisdAe-

1-40prf&--fdig-OP Bit) x 64/i reIZ.k 3aoys.771?9v-Dic
4/1704c ami 7 z uto
YlluraPtiT ira OD 11
4?"0/1440fri--f477S 01 Bit

c_1062)—L
Pr" r9 '71.1 f g.i.--a

RELATIONSHIP TO SPONSOR
SPONSOR'S NAME

FIRST

cl,)/a)"'L
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY

PATIENT'S IDENTIFICATION: /For load or written entnits, pirc Nam , last hi:Lffidilfr
• ID No or SSN; Sag Date of Mk liankruidei WARD NO.
PROGRESS NOTES
0.)(b)-,/
Medical Record
10111

STANDARD FORM 509 MEV. snagroP.esabet1 by GSARCMR FP1411(41CFR) 101.11.203INI101
USAPA MOO
MEDCOM - 20863

DOD-034438
I
FIRST NAME
I
MIDDLE INITIAL ID NUMBER

DATE
Are Bcovi"7114-mm. ins(/1

/OM 5

Stuary
Lez
4414/4 Mil
t' dm) a/tcff,vo# dam. F 4

s1-aksz`zomo hewind
/0114114401/0 idAlk* ar/fae 7:4775 OD Se i*el) 47-erArtF 7`-‘77s. a ell) • Aors (fern is-
itoiR.frr 477,r eo

/iren7:-&DM-e(7r,roD .0/4
)(mew e.c-ta a'
Alz,WP/x/r/v P777S oO RD
Dowdy zoitin t7413,0e BID
%/wpm MitiLligo B/L

(REV. 5/1999 B CK

111.1 09) (b)-1
.00

c108,) -
MEDCOM -20864

()OLEO-TG

DOD-034439

I AUTHORIZED FOR LOCAL REPRODUCTIONMEDICAL RECORD PROGRESS NOTES
DATE
NOTES

124-00"
(. ID) (6)-

610o) ut±,
.qruntie
) Intdijki).
,

(c-fiq)--N J-11 anrU otfac)
linctit IAL dm.

warrct, owl (yo3Late/3
tichiat Lku, Gfrat.doo it

Mir
(b) lb)-2
RELATIONSHIP TO SPONSOR
SPONSOR' NAME
LAST

SPONSOR'S ID NUMBER FIR
(SSN or Other)
IMI

DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY

RECORDS MAINTAINED AT
II

PATIENT'S IDENTIFICATION:
(For typed or written entries give: Name - last, first, middle;
REGISTER NO.

ID No or SSN; Sex; Date of Birth; Rank/Grade) WARD NO.
II

PROGRESS NOTES
Medical Record
t)

STANDARD FORM 509 (REV. 5/1999)
Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(13)(10)
USAPA V1.00

MEDCOM - 20865

DOD-034440
M EDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY
POST­
DAY
MONTH-YEAR

DAY
19 HOUR It •
PULSE

TEMP. F

(0)
(.)
TEMP. C
105°

40.6 ° 180
104° 40.0° 170
103°

39.4 ° 160 0
102°

38.9 ° 150
101° a)
38.3 ° tr 140 8
100°
MIME

37.8 ° 130
99°
T3
11111/11301111.11111111

98.6°
37.2 °

120 98° °37.0
36.7° -a 110
97°

36.1 ° 100
96°

35.6° 90
95°

35.0° 80
Cb

70
ISMIIMBILM

60
50
........

40
RESPI TION RECORD
k.

BLOOD PRESSURE
ti '11111-41711111e0- 111111111177.75-ZMWAIIIIIMINIII
C

a) HEIGHT: WEIGHT
a

C
0

"VAIMILMNAMillretEMM 4771111m211111

C
N
0

u0)
PATTEN
'S IDENTIFICATION
(For typed or written entries give: Name—last, first, middle; ID No.
(SSN or other); hospital or medical facility) REGISTER NO

WARD NO.
STANDARD FORM 511 (REV. 7-95) BACK
1111 (1.) N-It
MEDCOM - 20866

DOD-034441

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
IMPligi

. MONTH-YEAR DAY IIMBAIIWLrdefrO 5711111 1
eAllrMIUNM
2Trarit
.
41 • -ir.

19 HOUR t-Lcdrearit7/1 - - 1111107‘113111110 • • • -

•• • •• • • •• • • • • • •1•• •1••••
1:: ::
105°
1: : .
1 : :
TEMP. F

PULSE

•

•
.
•. . .
•
•
ME -: a .: :.
•
•: :- •: I : :, :• alreP
•
.... • • • ••• • ••
•
.
. . . . .
. .
. . • • • • •• : : : • • : •
. . . .
. . . .
.a•

180 104° 170 103c'
160 102°

150 101°

140

100°

I
03 03 W CO CO0303 03CA 03 .F al 01 a) a) -.I -.4-.I 0303CO C
bin i-, -.1 bi.) to to io :p.
0 0 00 0 0 0 00
(Centigrade Equivalents, for Reference only)
. .

. ' ••
a••• •• • • • • •• • •• ••
111=1•112112111=22
•. . ' •. •.

. .

• •
• .
.
. .
.... ••••
. •• • • • • •
. • •• • •
. .
•.
•
.
. .
riuml

. . . •
.
•

.
. .
•
: : g : 'gaga
.
•
•

.

•

130 99°
EMS
98.6°
ZEE=
.,
212•1121111=227J
212111 NI 2
givii

•119111• •I •• •
72
: :
. " .
m=M "
:

:

•: : : •
EA

120 98°

110 97°

•
•
-

1¦• • •• .••
. .
1=1E1111
. .: 111
.

•
•
•
III.
:. .: ..
I i
•
' • •
.

...
. .
•
-
••
" ' •• "• • " ,
11111.•
rim
• •• 1 •
:.•••:—.
111111111

.

100

.

96`'

•
.i.¦•=1¦No
... .... .... •
.

•

so

70

60

50

40

RESPIRATION RECORD
•
•

4." •
. .

! • • Q
-
0.
....
MI

•
II

4LIRM
• iti
g

. .
•. .
. .

. . . .

....
'

.

• • •-
. . .
.

. . . . .
-
roil
.P.•

gnus •

A
O.

/ I

" • •

.t.

BLOOD PRESSURE
P b3 105111111M1BIZIMIVIVISETSIMEr.

'Record special data only when so ordered
.
1157111111EINKIIMITINIII MIN C1210111111
Allt-P422IMM CZ 1PARIP.FArl na
1
PEMINIIIIIGOAM,Witril ralMAIO

HEIGHT: WEIGHT ..-4.
sti) 4
., AILMI111111111111111=talliglarilMIIMINI
La nmummalm„Ppalim
i&
IN NI

1.1

PATIENT'S IDENTIFICATION (For typed or written entries give -Name—last, first, middle; ID No. REGISTER NO
WARD NO.
(SSN or other); hospital or medical facility)

11111
) -41

VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511 (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 20867

DOD-034442
•
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT !DENT!F!CATION
DATE OF ORDER

TIME OF ORDER LIST TIME ORDER NOTED AND
HOURS
Arint 1-o !MI SIGN
()tb)-(1

Ph • mna ailritnet 2 to
.

NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION TIME OF ORDER HOURS
(6)1 10'4 NURSING UNIT 04)09 BED NO. Oa/.
ENT I F ICAT ION
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER 061 —f TIME OF ORDER 01)fMlf) X HOURS
NURSING UNIT / DA 1 FAOPRR19 4256 00) CO - 7-REPLA ROOM NO. BED Mita OA 0 ION • 1 JUL , WHICH MAY BE USED. LL)tb)-7-

MEDCOM - 20868

DOD-034443

MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
DATE
NOTES

/0

cl.)(13)-z_
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME
DEPART./SERVICE
HOSPITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle;
ID No or SSN; Sex; Date of Birth; Rank/Grade) REGISTER NO.
PROGRESS NOTES
Medical Record
STAN 509 (RE. 5/19991Prescribed by GSA/ICMR FPMR DARD FORM I41CFR) 101-11 V.203M(10)
USAPA V1 .00
MEDCOM - 20869

DOD-034444

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION
DATE OF ORDER

TIME OF ORDER

LIST TIME
ORDER
NOTED AND

I
f I 0,16

HOURS ,1411 FeCett.cre, SIGN
111

NURSING UNIT )
RO 41tra-it f
PATIENT IDENT

10 /iv an fs115 00 /cinio k Tr
Nti,)-DA DE TIME OF OR
(Iv IIM •0/C Maim
_,.......!

C 1 _..,iwimeam...2.morn,A.,2..,,.._.._ u* ,... -¦_1!!
III

0.)(b) -2
III
0 NATI

NURSING UNIT
Inw&cgrait,..,:ave...---0
P TENT IDENTIFICA
DATE OF ORDER.

TIME OF ORDER
///fro, IVir"

HOURS
04 13.Y2-cm /RD
NURSING UNIT ROOM NO.
4)(6)-1-

PATIENT IDENTIFICATION
NURSING UNIT
,•• .;;L:t.*"1: Z'o
irV 1
AL—'Z
s
REPLAcr

DA 4256 -
1 FAVRM79
:H MAY BE
MEDCOM - 20870 cb)(b)-7--

DOD-034445
CLINICAL RECORD - DOCTOR'S ORDERS
For
use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION
LI T TIM ORDER NOTED AND SIGN
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT IDENTIFICATION
NURSING UNIT
PATIENT
IDENTIFICATION

NURSING UNIT
REPLACES EDITION
OF 1 J111 77 uu ca. " li MAY
BE USED.
MEDCOM - 20871

DOD-034446