Medical record of Iraqi 30 year-old male with a tibia fracture. The medical records do not give any indication as to how the patient received his injuries or any personal information on the gentleman.
¦ M wI 1. REPORTING MTFM 1 2. .. IF LOCATION
ADMISSION AND CODING INFORMATION
1 1 2 I 3 1-4 5 8 ! (State or (b)(3)-1 cCode)
For use el this kern, see AR 40-400; einponent agency is OTSG
3. REGIS fER NUMBER NAME (Last, First, Middle Initial) 4.PPAY GRADE 5.MSEX (b)(6) -4
9 14 15
18111111E111111
16 1 7 18
(b)(6)-4
6. DATE OF BIRTH (Y VYYMAIDD) 7.PAGE AT ADMISSION 8.MRACE 9.METHNIC RELIGION 19 20 21 22 23 24 25 26 27 28 29 30 31 BACK-
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GFIOUND
10 LENGTH OF SERVICE ETS 11.MFMP V 12.MSOCIAL SECURITY NUMBER
32 I 33 1 34 I 35 36 37 38 39 40 41 42 4 44 45
b)(6)-4
r
I
q mil
ORGANIZAT ON (Active Duty Only) M1 . MARITAL STATUSM 1 HOUR OFMI BRANCH / CORPS I ADMISSIONM46 1 I D-02717
I I
14.MFLYING STATUS " 15.MBENEFICIARY CATEGORY 16.MZIP CODE OF RESIDENCE
47 48
49 50 51 52 53 54 55 56 57 58 59 60 61
17. UNIT LOCATION (State or 18.MMOS
19.MTRAUMA PREY ADMISSION
Country Code)
62 YEAR
63 64 65 66 67 68 69 70 71
N \ Na
20 SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAMErRELATiONSHTI; OF EMERGENCY ADDRESSEE ADMISSION
ADDRESS OF EMERGENCY ADDRESSEE (Inciude ZIP Code)
ld GO /
i I
-1
I NAME Al(b)(3) I TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21, MP E OF DISPOSITION 1 22. MTF TRANSFERRED TD l_ 23. DATE OF DISPOSITION (YYMMDD) I I I
[73 75 M 79 I 82 86
1 76 177 L 78 I 80 81 83 I 84 1 85 I v • I 1 I I I a 0 - 1 ril)i,...-MI
24 CLINIC SVC • ADMITTING 25.MMTF TRANSFERRED FROM I 26.MDATE THIS ADMISSION (YYMMDD)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 10
27. LOCATION OF OCCURRENCE (Battle Casualty Only) 29.MMW OF INITIAL ADMISSION -- 29.MDATE INITIAL ADMISSION (V V M MD D)
103 104 105 106 107 108 109 110 111 112 113 114 115 116
FORLOCALUSE
TGA"-P
...
ADM all 3:/)(6)-2 IMul (1;)(6)-2 u-M¦M/lir AIIIMITIAIrt 1, CO.. (b c )(6)-2
LTC, MC
GENERAL. SURGEON
DA FORM 2985, MAR 89M LU+i rota (j1 MAY I )l L IL ...
MEDCOM - 5208
DOD 12420
'7- (C) t
iP
1. REPORTING MTF , IF LOCATION
ADMISSION AND CODING INFORMATION
I
1M 8 OWN or
,b)(3)-1 Country
_nt..._ Corlt4 For use of this hum, me AR 40.400; tuotionent agency is OTSG ,:,:::1...1. ....:-I
3 REGISTER NUMBER NAME LaMFt., • • le initial) 4.PPAY GRADE 5.MSEY I:4(6)-4
b)(6)-4 16 17 18
1:41ZE.,—. 1;11111111Elimmiiimmill= IIMAI IR
B. DATE OF BIRTH (Y Y Y 1' MMD D) 7.PAGE AT ADMISSIONM8.MRACEM9.METHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 -'' re
vim BACK
GROUND
MEIN q d MUM / InLiam ,r _ f --
10 LENGTH DF SERVICE ETS 11.MFMP IP'M12.MSOCIAL SECURITY NUMBER
32 33 34 35 36 37 38 39 40 41 42 43 44 45
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF BRANCH I CORPS
ADMISSION
46 d-792,-P
14. FLYING STATUS 15. BENEF CIARY CATEGORY 16.MZIP CODE OF RESIDENCE
4 7 48 49 fl 51 52 53 54 55 56 57 58 59 60 61
==lia
PAL1111111 rJIVAIGIMIOEICigir•
17. UNIT LOCATION Mate Of 18.MMOS
19.MTRAUMA PREV ADMISSION
Country Code)
67
YEAR ...„
62 63 64 65 66 68 69 70 71
.....
___M. .kNO
-1--NI
=al WiliMallinEWISIMI
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION
ADDRESS OF EMERGENCY ADDRESSEE anchors ZIP Code/
r.3 leGO/
NAME • b)(3)-1 TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION CI `I AI 141 D D)
75 76 77 78 79 80 Ell 82 83 84 85 86
Milli (rnik
4/
24MCLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26.MDATE THIS ADMISSION (YYMMOD)
87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 10
A z, n ra APC 0 . 5...
27. LOCATION OF OCCURRENCE 28.MMTF OF INITIAL ADMISSION 29.MDATE INITIAL ADMISSION (Y. y.,Al M D D)
(Battle . caMialty Only)
103 105 106 107 108 109 110 111 112 113 114 115 116
•
FOR LOCAL USE bY ..... V:)0
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gMi 0
LEI.( PI
1-0;1
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ix *.- %cf : ,-7106. i 7 P r") 7 9 o.i ".'•1 5 i , 7M
7 ,1 CL:7 . lc/ 0
i
Aomi,MI (h)(6).2 3 aw‘pquired) ' SIGMAomiTTINr; (1 FRE
..
, !VI LJ ;b)(6)-2 1/)(6)-2
`11 C.,, MC
GENFR•i._ F‘IRGEON
M
DA FORM 2985, MAR 89 . . LUI ¦ lull LA MA r /9 I L I E
MEDCOM -5209
DOD 12421