Medical Report: 31-year-old Iraqi Male, Mosul, Iraq (0180-04-C1D259-80227)

Medical record relating to investigation of 31 year-old male enemy prisoner of war who was picked up in a raid and brought to enemy prisoner of war camp. The detainee was interrogated on March 19, 2004. The report notes that detainee was bruised, experiencing pain in his foot, had multiple abrasions to his back, chest and legs, and was unable to walk or extend his ankles. Periodic check-ups occurred through July 8, 2004.

Doc_type: 
Medical
Doc_date: 
Monday, March 8, 2004
Doc_rel_date: 
Sunday, April 17, 2005
Doc_text: 

For Official Use Only Law Enforcement Sensitive U180-04-CID25~'-~fit4-CID789 MEDICAL RECORD PROGRESS NOTES REGISTER NO. NO. PROGRESS NOTES r b)(S)-4 Medical Record STANDARD FORM 5091REV 1.911 [b)(6)-4 Pr.scribed by GSAIICMR. FIRMR 141 CFRI 201·9.202.1 MEDCOM -686 ----......"....","" ...~ DOD 003749 For Official Use Only Law Enforcement Sensitive 0180-04-CID25B_9M~2¥-CID789 ..L..J.~ .... -;;JIo .... Theater 1 rauma Keglstry KecOra I For usc oflhis form. sec DA PAM :l!XX; the proponetlt "Seney is OTSG -----.-----------------------------~----~----------------------------~ ,\UI'!-!'.\F.lrY· SOME IlEGULATION Pt:h:·t1~1-· T'.. lli(\\ ~(Ic a S13ndarl\ m~ans of doem.nenting c,)mtlat trluma :or care at echelons \-3 ~ H.OUTi;-:r L;~;i ":. Th,,' [I:a'1l;ct Roulin~ U$:;s" sci foroh al th.: Dcginningnflhc AnllY com(likllion ofsyst~ms orr~cord~ notice "I'Piy. OIC;( I.('"!,(U'· Th·, i: NO[l!cted h~Q!t!1 infonnniioll. 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Date of Birth; Rank/Grade.) ~b)(6)-4 CHRONOLOGICAL RECORD OF MEDICAL CARE ISN: l Medical Record STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR USAPA V2.00 COMPOUND: FIRMR (41 CFRI 201-9.202-1 -~ ,-) 'U J •• ~ FOR O.l:'/:'lUAL U~ ONLY MEDCOM -689 DOD 003752 T.'l.~leoter T i" \-I' ... :::-;~:,':':~~':'1" ...:~~·~~-:::-ru·.Qi.~O-04-CID259-802i7.... ..)L Ll ~ t.._ l.\:,t". l'·_'%...·t~Q,.::;, .. .I..~ ~.'-....... ~.!"..'" Fer usc of this foml. s,-"" \:!'. 1':',:.1 X\"I:: ll;" 1!;(l[)Ollclli .)g.CIICY is OTSG ~--------------------------------------­ .. \[ITHORrTY: SO:VIF. REGULATION PURPOSE: To proyidc a stanumd mC3n5 ur docwnenting 1:..;lrn!I:I: :r..I(;m:l lor care at echelons 1-3 R\)UTINE USES: The -13lailkc[ ROllline Uses" set forth at the bcgilliling. t'!" 1!1t: Army cumpil;llil'rl ofsystcnls orrccords lIotj~c apply. DISCLOSURE:· This is vrolcClcd he,lIth information. HIPAA laws ,mpl\' MTF DESIGNATION: ,N-" I CASUALTY SSN: f b)(6)-4 ,It', ,'r .. .' .... 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TREATING ORGANIZATION ~1LIm.~~-Y:{J~:~:~_--.!:5~~O~3~O!-W_'_·'-==~~~ft---=!-r.:::=..-O_C'=--..L!.R1:.:..c~.N~A-ll_~_._-~~_Lq_:.......J...1------",:=-----YJ'8:;·C­ t6 5 {" t( 0 !l1!. OJ7}..':dk _ , 0'2-- _. _____-.-------. --.,- b~.",-U ~ --+1_O_t!_IJ_'3i_""'_It_,,_er __. f23~_o_--=iLf5BiJI(:!k_.~·_2L «PI :z~L~__~U ---~------.-----------------..---.--­ .-.-------0--___.___._. r . -.--.. --.. --.----f--­ _._--------.. _._----­ i -----.--..--t----.------.---..-... ---------... _.__._._---_.. __. -' i I _._. __.. __... _..._--_._--_.-........ _-----_._.. _ .. -_.. _-_..---- I .--.-.-.------f---- I ~~=~-==-t~~------·-~-~-··~-.--~-.----.~-~-~=-~~.--·-·=--------=~~:.-----=--.-~.---.-..--. I I ------+-----------------------------_.---.'-----_. -_._.- I PATENTS DENTFICATION: (1'01 typed or ..,*" enIIIas, gfve: Name -ract, Iht, middle; If) No or 8SN: Sell; DiIl8 rREGI8TER NO. ----.. -­ofBidII; ~1JIrJG"",/ NAME:(LAST, FlR.ST)fbl(6l-4 I SSN: CHRONOLOGICAL RECORD OF MEDICAL CARE . M~~R~ DOB. UNIT: RANK: STANDARD FORM 100 (REV. 6-87) Preecribed by GSAllCMR FIRMR (41 CFR) 201-9.202-1 USAPAV2.00 SEX: STA.TUS:(AD NG, R) FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY MEDCOM -692 EXHIBIT ,.. 7 DOD 003755 01 ! . , ) " \ y· ... 1 \ "'-"~' -•...-~-..-----. ----.-._,..-'--­ ..-...__.-.._---------. -----.-..-·---·---·---------···-----....:.··T";..----._-_.' -"., .-.-~--.­ ...... ---". -_..'---._-.' .-.. -. -.---. ---_..__..-_....... _._._--_. r~ ... :.. ',;. lIt' "'~ . ". . ;" \ !:,:r ..-~ \"'r i· ',' i," "\,'. :,1' .: J..'~.' J" : '" ... 1/ ­ .. ~.' .... \JIiAP'" v,z.OO RANX; SEX: STATUS: (AD, NO, R) FOR OFFIC~AL USE ONLY ~AWENFORCEMENT USE ONLY EXHIBIT DOD 003756 MEDCOM -693 -+ ----"'-~---. -------.1!I---=--=-------------------------:....;:----------------------­-"':...---"-,c----------------..----­ I "- I --­ -'~- H08PtTAL OR MEDICAl FACUI'Y IlEf'AATJSERVCE RECORDS ~TAlNEDAl -.. SPONSOR'S NAMI: ASATlONSHPTO &POMSOR .' 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FACLJN SPONSOR'S NIUE ST....TUS SSNI1D NO_ DEPARTJSERVICE RElAnlNSHII' TO SPONSOR RECORDS ~T~AT -P-AT-IElIT-S-ID-E-NT-IF-ICA-T-IQ-,.-:"'""'!:!(FoI~typItd-or-w-fiIftffl~·-_-ie~$-,QMl~:"!!H"-m-O'"':-laSf.~4m.=--RIIOUIB--;""'ID~No~or~SS~N~:s.~.-;1AIe~-WII-=RE-:::G::-:lS:::TC==R:--::N:-::O-'----l""':W~A:-::R-:-:::O-:-:-NO=--..--­ of 8irt1J: RenlclGtIIde_} . NAME;(LAST, FIRST) S N S. : CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record DOB: .._____ STANDARDFORMSOO (REV_6.a7) UNIT: RANK: PrascrlOed by GSAACUR FIRMR ("'1 CFR) 201-9.202-1 US.....AV200 SEX: STATUS: (AD. 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HORPITAl OR IllEOle:AL FACUTY ----+CS=-=S-N1: 6TATUS -:C1Q-:!OI-=-O. . -­--­---+ DEPART.JSeRVlCE RECORDS~TAIoIEC,0.1 :-RE1A=-:c:-TIOII:----:-SH-P-T--O-5PO--::-:NSO=-:-cP.:----~-- PATlEhTS DEIITFICATION: (FOI'l1p1Jd",.trrl/IIwr --,.II''t: Ha",..1NC, 11m. mlOdM; i5'"woorSSN: Sar:DIIiII I·REQIST£R NO_ I WARD NO. f118fI1fl; RriIG""J J NAME:(LAST, FIRST) SSN: ~o-;--------, CHRiONOLOGfCAL RECORD OF MEDICAL CARE b)(6)-4 MedIcIII Record DOB: STANDMD FORM 101 (REV, e~ i UNIT: Prwc:fI* by GSMCUR FlUM (41 CFR) 201....202-1 RANK: SEX: STAnIS: (AD,~G, R) . FOR OFFICIAL USE ONLY LAW ENF;RCEMENT USE ()NLY EXHIBIT ..;.. MEDCOM -698 DOD 003761 __.­ , I .~ aIBirtit: RMtJrI9_-1 NAME:(LAST. FIRS1) CHRONOLOGICAL Al;CORD OF IIEDICAl. CARE SSN: Medical RecordDOB: STANDARD FOAM.oo (REV.~7)UNIT: PrescrIJed by GSA/lCMR FIRIIR ("1 CfR) 201-11.202-1 USAl'A \Qj)() RANK.: SEX: ST ATIJ8: (AD. NC. 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It) FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT r / ! / MEDCOM -701 DOD 003764 0180-04-CID259-80227 ~lC-+_..L..=:.'--"'--~__'=~_...J......:C"_:7L,'ft?:Y:='2 ~u .t;:~~ (~c.s t-*-'t-i-J.! ~.~_ ---.sM4-~.)-,uc7'/rI~ /c I - ('t ~...~..(~ C; /;e.,-:~-b/e. St "/#All-~_.6{l4. V4?~~ --"'O_O------'--Y-"-5__-+·i --'-r.....:.!_~jt2__ /}J .._ /;?f?A!.~ fe,::zJ. -;;~+-.5Cr2~//J(-::____ (] I '-I_~ l! PI 5-/rLA... ZL ~/.A-)f..­ t 2-( C Z. C C G /6, 0 {..~,c.._.~"_.----!p'--._O~;;_;;---_-------L.-'-------r b)(6)-2 o 3c-C 2( ({L.:ftIV'G"7' ;lJk6. _________ (I 1 cC-.. 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PIllST) SSN: ~rb)~(6)~-4~'-'-------~1 ~ac!f.EDICAlCARE DOB: ,_______-' • STANDARD FORM IDO (REV-e~7) UNIT: -PrwcrIbed byGSAIICURRANK: FIRMA (41 CFR) 2OHU02-1 UMPAY2.DO SEX: SfM\f~~~USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT MEDCOM -702 .--­, DOD 003765 01S0-04-CID2S9-S0227 ________-!-O::.-;..I...::1.=-7L.--'I'-J!...1....!../~I~~r_"",,!.L Sc1 C L (;,ppr~t.,1 .Jd...z,~(}________________ I o ZI-j ?1 I,k.,v1 Ltl'ptf-'/" D /jJ J 16­ ________+-____ ___-L..___ _________________ ._ ~~~L-~=c...:.... ~~ ,"./c: -.., ~,-' -; ... l. _ '--I Ie. 'I,~_". I() Z. oS.s -/:-:.,.. i ~ .::lfJ '/ , . ,f"'. . ' . .- I .... -.--_ ..---,--~------....-..---.-.. ------------.. . '. ~-. -~­ -....... -----------''-,:--------------­"-... ------t-----------------------------------"----------­-.---1------------------...-.-----.-------.-----------_.._-­ .-........-._ .... ------_.-._------:-----_.._----­ --'------.----.-~­',1:' ;,'i:':::;.. l. Fl.t.I~:LiT':· S~!:'~'_::: I ~!:~··c..;~T .ISEFi\;ICE IPt::CA0S M ..~j.... 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LAW ENFORCEMENT USE ONLY EXHIBIT MEDCOM -703 DOD 003766 01S0-04-CID259-S0227 AUTHORIZ 0 FOR LOCAL REPROOUCTION CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTONS, DIAGNOSIS, TREATMENT, TREATING ORG_ANIZATION (Sign each entry) ON f?1&tt{ /1./ 6iA-!/?... ~KI/"J6-c: ,~~~'., ;4IROK UJ CL-I O. . i -"'" _________-L-_______"-.~________________ i -----_.--.. --.------.-------..-----.---------------.-~--.-_;:::~:;;=======r--.-----------.--.--.---_.-------.------_._---.--.--­ __ ·r)(6)-2 ~_._ b)(6)-2 -----_.----_.._------------------.-------------..----.--.-:~~ I ' \. i ( ~~=~==.. i ---------­ -----------------------1 r--.- I i , --.---__--__~I--____------------------------------------------~--­ i I ( STA7\.jS ) RECORDS MAINTf.,U..'EO A r -+.i_____________-Li____._______._::., I ! SSrHD ~IO_ IRELATiONSHIP TO SPONSOR I --------------------------------------------~--------~-----------.---------_. ~T:t~H'S IO[I"JTIFICAiION (F()I rypei or wflf:e,1 enrflt~s. gIVe: Name· !a:sr. firsr. rnid(Jie: ID No "f SSN; Sex: REGISTER NO. WARO NO DBte ot Birr/): Rank/Grade.} CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 IREV. 6·97) Prescribed by GSAIICMR FIRMR (41 CFR) 201-9.202·1 USAPPC Vl_00 FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT " j. ',­r',!' 'iJ MEDCOM -704 DOD 003767 0180-04-CID2S9-80227 MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTONS, DIAGNOSIS, TREATMENT. TREATING ORGANIZATION Sign ~Bch tmtry) ttrn1Lb)_(6_)-2______----~\r·------------­ . . ---_.__.-..-._.-.._-_ .. -.-,_..-_.'---'-,---"" .,-----'. -~"'-~ .. -'. ---.-----...·.=b=)(6""')-2~------------------------I-.-.--..------.... .--­ -. ----.-.--.-------.....-.----------.---------.------l 1------.----­ f--------­"­................ ---------~---------------------------­ . -------------~--------­ ---.-.-.-----­ --.---.--~~~----..,--------- S-':'"...:. :" ..;$ '.::-r., ,oot·'i .!SEI~VI;:E ! .q;:':C.~O'5 MA r-:rAINE: AT ! -----_. i • ------------------~ ------~---------­ ~·.;:O....::~··_·:.~s ~/v.·i:: i 5$1.. ;C Ir:. ,nelA TlCNSHW TO $P·~)NSO"'. I i -A, ""~[Nl?S I!JE,'n1f.C';-j;ON (for rYR#-d 01 wlJrr,n tlnrrlld. gi~'~: Nttr:l~' ',ast, {i."st, miOdlf1: 10 No or 5S"'; Sex,' REGISTl!A NO. 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LAW ENFORCEMENT USE ONLY EXHIBIT . r .-/ MEDCOM -705 ; DOD 003768 0180-04-CID259-80227 MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DATE S~-MProNs.-DiAGr.oU:;IS, 1'~~" irvil:'~ I. rk~TIN\j OI1GA":'''!':N~IZ~A:-:T::'IO:'N:":''''::(Si~'g''''n~.a''''c!'l'h-.,,--:-try.-~~­ 1200 ,__ ,_ '______--i--",A.!""'-'"'... i:...-.t.r,~_ -',,--,A!'':'''()L-_i-i.:...tj.(!/L!/';;1.'i~b""''''''''':':B~...;O~A~~.!.!J.~~?_-'':''-''-i.i-=j~",;.5"Lt..:,;'-;,,",--,v:,.I,,,,J.--,,,'"",,,~C;--L1..!.,:,.1..,.,w",,.iJ1{'::",:L'-rl_-,-,",,-,-,-'Lj.1 . 5 to ""\ ,I" I 3J.( C; P1 _:: r-i,,! k ,~~~\~'~~~(~l~Lf~~~~'~~l:...:_______________________________________ '~I/-.' , '­ -----,----­ , [ ----..--._.__ .. ,..._.... ---_..._..... _----..-....-......-......._--------.._.....__ .. _.... _" ...-"-.--._--... 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EXHIBIT ! _ • __ ~______._••••~-------.-----.-. _ •••J __'" _ FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY MEDCOM -707 , ~. r -! It""'lv~;:.gPlrJ!;;.~~~ 'u-t---+----t i 1 . -J-,.' I" .----i ! i· .-J t-. ! I I Breathing: I • ~ 1 '. !I jo. ----:-....-t-.-.-+-_.__.--; ~~-t----..-.+-........-L...---.-....j ; I _._._! : u_..-L__I i .Bluud COmlJQnents ". ";' ICin:lllalion: I 1 I oLh"" , ________.Jj L..._ ~ I MEDCOM -708 ---_._­ ! Bre'Hhing: ~ ~ I !Cit'i:ulalion: I ! l i ~ Olher: L.._. __ I i .________~~______J! b)(6)·2 ............._--­ ~.. ...-._..-... _-------l~---r=="-==F-":::::;""?\;'::::"-~;--r'. _ ........._. __ .. ~.•___•••.•__•.._~,___-L.JL.:!'.: .,t._~.J..q..Jd.. ... ...---.--.........~-...-.----­ -~ _....._--._----­ _ ............................ __................................---­ .... -............-----.......~,......-.---­..................._--_...._...._-....._---­---_.-._......_----­ __ n. __ ---­ .___..__._.c:..-_____ ----.-~...-...-......,---­ ._---_._-_.•. _------------­....-.---..--~.-.-------.-'----­ r-............--..:.~=--..::·=-::·~::-::·-::·=========::_:::--J ; i FOR OFFICIAL USE ONLY i i LAW ENFORCEMENT USE ONLY MEDCOM -709 .Bloud Coml'.unc~tl ITransfer i~~·~·~-lc-'t-i-c)l-l-.S:-----.. -' I I I ! i L._ If')i~epared' . , B.\i; ~ I . . 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'-'--tSSN;Iii-NO. -"--" h~e-l.a:T~NS-HIPTO' s-P~~S:.R~~~_~J.. -.-:~:~~. _:=:: _~_~~.:~-. rATlENT'S llENTIFICATION: {Fo.' typed or.w/1l1en tHlD1es. give: Nam. ,1.Sf, ~~f. miCiflIlJ; ID No or SSN; Sit.; D.1e REGISTER NO. WAAO NO ofBiI1h; R."lVGnJdfI.} NAME:(LAST, FIRST) SSN: r CHRONOLOGICAL RECORD OF MEDICAL CARE b)(6)-4 Medical Record DOB: STANDARD FORM 100 (REV. 6·111) UNIT; -Pr.tcrlbed by GSAllCUR USAl'A V2.00 FIRMA (-41 CFR) 201,8.202-1 RANK; SEX: STAMIt~m.@AL USE C) :'~LY LAW ENFORCEMENT USE ONLY EXHIBIT MEDCOM -710 DOD 003773 UlS0-04-CID259-S0227 DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANI~TION (Sign each entry) :: 2-'2..09___ lc.~:~~ci.:~~H.r:: i~~~~.:-r:~+ .J~.c.p_.J2_._~'-rr..~&1 ._C_'\~iI"'-J--.. _.-. _____• n Vf!'Q.1 ~v-v-~'-,~,~ ___ _ ~SW~jr:--'l..-~~.,...~~ z.~_2:L___ .Lf~_l::k_~.bL~t.~C!.L:Y_~~ ~~(!;r.~r.?d~J __~_t¥~_~____._____ _____ . ;~QJ__~ :_~.:._-:-0~c?-. __(;-'7 .hD.~_ 1'!4{\ _ ____ .. _.._______ . b ' •• {I 2E~. ___ ! 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"';1' DOD 003774 U180-04-CID259-80227 -~.-" ---...-"', -. ..-. -------.---~ -----. ""'_._.'--,.-------.----~-..._--.-_.__.. _-"-'--""'-'---_"'-.. -,. ---.-.._---'---._-,----_... ~. :\'1EDICAL RECORD PROGRESS NOTES .-._._-----------------_.-.------~---..-.. -.---.-... -----.__._-------_._.. ---....----_.-..._---_., ., .........._,_....... ----, L~~__SjJf-»-C1 it·tb k ,\ytH.A,/a.1j 62:1-'-'~ -£ I%'4 .~_______._._ .. __ ---. -----... --.----~ \:;-~f ~~WLL~: kh ~Ir:v" .. ~._... __.___. . ..... ..---...---..--------.-~--~-WL b__ V'--Jt4ift ~----------.--.----..--.. ­.-...--.... -..---.--..-------M..k! It''s, (.. llJ0\C~.s: Att!--fiy. k~.__.. ____ ...__ ---...-....---.-.----.-.-...-0/.:-A V$ ~ ---. --. -..-----...--.--.---.. --.-. -. ------.-....--.-.---....----'-'--'-'-" -. -.----­-..-.-..-.-.-.... --...--~--~ L.~ '-Av1t ~~ ..£vr' ....-.... ---.....-...... -.. -----.--..--..---*==. Wlu Jb}1 L ~l3a..(ev-$ ~ 1LCJiJ b$0~~ (Lff'CAK! 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F:RMR ':+i CFR, :OJ:.,!! 2:·':'·' [b)(6)'4 ~FFICIAL USE O~LY L---'Lr-Alr"VIvvo-J!j""""""I'IFORCEMEN'1' L:; E ONLY EXHIBIT MEDCOM -712 DOD 003775 olS0-04-CID259-S0227 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. L.IST TIME ORDER NOTED AND PATIENT IDENTIFICATION 1 ~DATE OF ORDER TIME OF ORDER II: I~ HOURS I.... I~ TY\:lr Of SIGN 'bj(6j: bI CI) )(6).4 r L-.---~---­ r b)(6).4 1(1) LFr:.~ C_ K ..J, J: V Fluid Vtt4t' X ·T· l Jow-:­ tb ·15CLlL'LV '\ [ fb)(6).2 ~ NURSING UNIT ROOM NO. BED NO. , ~ , ~ TIME OF ORDER b)(6)·2 f k X-e.fGQ \0 t'WY tOe b-ict IL­ ~+--_~~Jr:.-1·V\.~_~~~ ~MJ~ft(~ \ FORM DA 4256 1 APR 79 EXHIBIT MEDCOM -713 DOD 003776 01S0-04-CID259-S0227 CUN!Cf1.t m:GORD . DOCTOR'S mlDERS for ,,51 '1t !hl~ fl·'"" !,e~ /,F 40·(;if. the proponent Jg~n(;y i~ OTSG THF' OOC':TOR SHAl L. R;:C0R() DATE. TIME AND SiGN fACti SET OF ORDERS. IF PR08l.EM ORIENTED MEDICAL AEU)HD SYSTEM IS uSED. WAITt PROB"'!:"" NUIYI8EH IN ':;OlU...N IND'('ATED BY ARROW BELOW. DOD 003777 (See Innrucrions on Back of this Sh~tJ 0180-04-CID2S9-B0227 NSN 7540-01-075-J7£ LOG NUMBER EMERGENCY CARE AND TREATMENT TREATMENT F ....CILITY (StmrtpJ (MeClica! RtlcorClJ ARRIVAL TRANSPORTATION TO HOSPITAL CU':!RENT ~~OS:/tetan,'" 'mmlUt-HISTORY OB 1~1'KVM " (Attach ell'" enro, ute .heet/ L'l:ation and other d,ata/ 'j 0 OTl-l,ER~Gr:if») TIM DATE -~ ~ /vi ..j" "-PATIENT .~.:::-,-"", , O PRIVATE' , ( ~ ,--1-'1 .....v lrl'J~,T,H I:A ItcJ.:~. 0 ~;~~~l~pecify) AMBULANCE V:'1f "Lt/J ALLE~GIES tX\.t(,ti-PI"'t P '~'cD-A- PATIENT'S :-!OME ADt~UTYSTATION (Ci~. Slate and ZIP Code) HOM", TEI..E. NO. (Jnc. ""'.. coa") CHIEF COMPLAINT(S) (Include symp tom (5). d... ,...tion) POSSIBI..E THIRO PAR . PAYER? DYES DNO 5t'--~ (1 C:'1 'f-J\ 0 C~ 1EMERGENCY 1 ITOOAY 172 HOURS I IROUTINE )"OMIT. TO HOSP. UNIT/SERVICE V --S:=-~L0 CONDITION UPON RELEASE IMPROVED UNCHANGED DETERIORATED 1', b)(6)-4 O·OFF wi' LA :v ENFOI ' [b)(6)-4 MEDCOM -715 DOD 003778 MEDICAL RECORD· PATIENT RElEASE! OISCHARGIHI89:JOOCIms9-80227 DIRECTIONS Ti) Of! Ci)rnpI8tec.J tty ananrfinf} prU1/;der 3J1(J other SlC1ff en t!ITle 0~ L;Cl{Jt'(\[ n-!IC:;-~;-~l~;:i9 a~ji.it.I-~1l1 ~)r'~I'~t:!dU1~~~j:;;j-~ Gdl~trr.d'rnent or discharge from an 'npatient hospItal slav· t--------~----'-----------_._---------.---- SECTION I SECTION II ~-----T-O-B-E-C-O-M-P-LE-T-E-D--B-Y-P-R-'-V-~-E-G-E-D-PR_O~V~'D-E-R---_~_~T-C-'-B-E-C-O-M--P-l-E-TE-·D~8.Y OTHER STAFF. AS APPROPRIAfE 1. DATE OF PROCEDURE.ADi,1ISSI0:\ .tJMA~.O~ DI::"·'·:S,~II}Nt:)~·C. C-.,.. , ::':i ~-..-.~~-.--'- ADMIT T i:JC:OIAGNCS:S v\'\VJbpk~._. CQ.Y\ht.si QY\5 j :3 PERTiNENT I.IB. X RAY mJDiNGS 6..NJ{OJ..}\OIi\.~ ~ rv~ PV\ ..XYa1.(S ... 'J' CK. It.~ r-: Cs .__ _. . .3\Iq.-Ck, ?6',(X)l); ALrJ:S~; A.ST 330 t ~nli . ;). b .... ...- I HAVE RECEIVED A COpy OF AND UNDERSTAND THFSE INSTRUCTIONS fb)(6).4 FOR OFF l'~-:':-;'~~~;~:;;"A;;:";S;~~;liiH~;'",;,;,;;'--1 MEDCOM FORM 691·R (TEST) (MCHO) MAR 99 P.9[V IOl S :;!)J'I~O,\JS "Pc 08S0LFH Me 'J: "" MEDCOM -716 DOD 003779 "u 'MUI'I~t:U FOR LOCAL ~l1ON ~NO~O-04-CID259-80227 AEDICALRs::ORD DATE NOTES ·-·\-\-~-\Q-~-Oo..\-:-+--'·-·'--·--'---------'--··-·----------------------­ .--''-'''--'·~o.::O''___+__'Cl.cl-'''' '. ..•,. \i.al~'-~('s\-'-''''''-e-\..·,-,,··\. --·~\.G"V'\ f t2 G I ~15~,,-'-,-(._____ .. =)-...,....:,-''\: p(~ ~ '--': '--I-• . • \ C""'-~ (, . -,. ":-'-. ....c.·, L·,.v '"v~ ""-••. ~i;, '-''' ..... A '". '~.:J ..;.-'1,:: ·"-c,,,,· 'I \ . :"'-....: [1.-""-..";;" \. ..0---~;-:::.-,';;,..-"':.1. --"')C . S ..1." ~-..--.. -.--) , .. _---. ' i so r :::\ _...:: ".' C\. ,,\..' I'::'..,,~; \ \..' ,,'\..-U... '""'.i~·'-___ '" '" ,.__"--.,,,,'. (L." 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Vl 00 MEDCOM -719 ----------.~.-.. , DOD 003782 lAST NAME FIRST NAME __._ ___ I __. I_L ____________~_____ DATE TCColLt) " NOTES ____.______._ _131·1J~~+____~-___{~JA)t1Lur~n:Luz~-JiL-~OJLidJdk) ~~__________ _ --.....--'\~--+---~.bU/rl-as i tMt~-}g~~__~___ ----i-------th:P~~', (f) ~-~~-~------­ ________+________ht~.----Jl~~-~~-P..pah~*--f-u-±!..------------­ 1 /)J Lr ~ -. _ . ..-.. ----'---'----~~,ill~-.:S".tID~--t~~ ________________ A~__ ~JlJ~~~---2.LeJ:!1Am~____ ._______.... __ .________________._ . ..-----------f-'-'I @ ~~~~~P--,k-------------~---·---­ ------.---­ ~--Gl~ _!U_ ---~-~fC---~--(f----------------.---.-..... _---l--___(:;)_j;~~~L-/UtK _~ _~~C~~~ __ ~______________ u _______• __ • .-f~A-(.}O lL1A'~ ­ .----.-.------.--.----~~ J.U~=-~--_:___::_-:-·---------------------------··---------·­_.._________ ---.--ill--~ ~---fClN~ ~~~___ . ______.________..._________ .~.-.---.-----.---------­ -_._-. 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'.-_.__._-_._.. _------_.._-------... ---------.--"-" -_.._---_.. --...._-.._--_._----------._-----­ ._----_._-- FOR OFF .Y MEDCOM -720 USAPA V1.QQ 0180-04-CID259-80227 AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD PROGRESS NOTES DATE NOTES ._-----_._-------------..--- PATIENT'S IDENTIFICATION: (For ryped or Wt"lrtel1 entries, give: Name· last. lirst, midule: 10 ,Vo or SSN, Sex, Dare of Binh; Rank/Gradel .Y PROGRESS NOfES M~~~Record )NLY Sl1i'Rtf1mI~RM 509 IREV. 5; 1 999) Pre5wbed bv GSAflCMA FPMA 141CFA) 101·112031bltl01 USAPA VI 00 b)(6)-4 MEDCOM -721 DOD 003784 ~-'-P;;t , (\L~rh.ed.--l--lL-~X)'J @ -i5_C1L~~-®,~___ _. ,a.z.;,~M.r(d'" --0..~_~~d_qa. pH &-;J.J7,.~.~:'2':::J~:., _______.__ -----+-I~.~"P~.~©-~~~~L:l:.~~~C-.-~~_ui:l~-"-T~_--'" I ' \ (1 --------l"~_L..L...f",::" "'ffr,.Q~_S()LQ ~~.&R~f'-JIJ · ~~~~ 1 __---""----_-fb)(6)-2 "Y ?--Yri-~ ,)NLY STANDA 1999) BACK USAPA V1.00 MEDCOM -722 DOD 003785 0180-04-CID259-80227 AUTHORIZED FOR LOCAL REPRODUCTION PROGRESS NOTES NOTES . /3 ~LtJ+ 1.Jl -f'"::\ __;&.L~______fr_Cr9-bS~_~_~£l-.J.-Vf~_f::::,-Jrq... i",() It:;. %cf"'.... _~fl\--:pI.1b. bJtr9~l~ ti­ --------~h~.....~-=--b::-~"-N+-\7 f).At c/o EmJ:: Cf-fRJrl IN © .rbwl h .... 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JtD-&~~ \L@ r.~~-~~*_ty fu1/\ 1'lt\.LLQ,b)~ __ RELATIONSHIP TO SPONS-OR-~-J~R~M~-~L i"''-----'!1 CW!Af·' I '"'' SSN", 0"." DePART -,SERVICE THOSPITAL OR MEDICAL FACILITY i PATIENT'S IDENTIFICATION: {For ryped Of wrirten entries, give: Name ·Iasr. first, middle: 10 No or SSN; Sex; Dare 01 Birth; Rank/Gradsl PROGRESS NOTES Medical Record rb)(6l-4 S~FPAM509 {REV 5/19991 Prescllbed by GSA!lCMR FPMR 141CFRI 101-11 2031bl1101 [b)(6)-4 USAPA '11 00 MEDCOM -723 DOD 003786 01S0-04-CID259-S0227 AUTHORIZED FOR LOCAL REPRODUCTION NlEDlC"'L R~CORO PROGRESS NOTES CEPARLSERVICE C (J\( VV\~ l Ll5 A PA TlENT'"S IDENTIFICATION: (F'or Typed or writTen enrries, give: Name· 18S/. fits:, middle, WARD NO ID No or SSN: Sex: Dare of Birrh; RankiGri1del PROGRESS NOTES -: C· j'l LY rb)(6)04 Med~~i1ford .!l.' \. ~)NLY STArftiM:M~lM 509 IREV 5/19991 Preswbed by GSA/ICMR FPMR 141 CFRI 101·11 .203tbl! 101 fb)(6)o4 USAPA '1100 MEDCOM -724 DOD 003787 01S0-04-CID259-S0227 MEDICAL RECOROI. ABBREVIATED MEDICAL RECORD P!3'mN8'lT HISTORY, OiIEF COMf'lAIN'T, AND CONDITION ON ADMISSION (!il'" dau of adm 1S",,71') 31 ~orV" Ctt" c?' t.. p w C.c~h..\,y"C cl L i'j ~I ell c{ 4-cI C1.'tf 7tA6~tV\G4 Y'A[,~. ~ Fie: OJ.D Y [{ 0) cy\ SJ C () 1'\ h.{ ~1 oVt S ~u,,~~_ (' c (~kj f'Al)~ d l,Lit~'V() -€f weLL 4 £1,l.b~tt-u~'lt fsU--tl.1h ~. ~c~kJ h E P"J CclI"t -hJ ~O lU~~!o1~. ~ wa.Lk-L' Jt1 I 1 ,n tre-,J. ~. ur »'(, c{.i ¢j C.),\.-l-::yf \Do.. 110\ (ctl fil c,c-id-Vl CrL/Jl}(:!.....G:[.\.~ r ~~. cJ{.t.t{ / l,;)~ 1L \ U i,J . fry c kJ I~VJA.l) tJ\}d.~-0-( r~·e{,'l.Lf+-t.i.rA I y~.. AU,. NKD(~' MEDCOM -725 DOD 003788 '1' ...., o CHEC)( II' CONTI ... ·JEO ON REVERSE "'. DOD 003789 0180-04-CID2S9-80227 r b)(6)'2 ~b)(6).2 i I .... _____1. _____ ...•. ___.___•. _.________.. ______._______________ o.r. 01 IJinh; Rank/G,.d".J CHRONOLOGICAL RECORD OF MEDICAL CARE r b)(6)'4 Medical Record STANDARD FORM 600 (REV. 8-97) Pr..crlbed by GSAJlCMR FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY FIRMA 141 CFFI) 201.9.202.1 USAI'PC VI.OO EXHIBIT MEDCOM -727 DOD 003790 .... ' ....-.1..., ........ It-- ~TIENTIS IDENTIFICATION (For t'r'ped 0' writte" flntriflll, give: NlJmll -lut, 'ifllt, middle; 10 No or SSN; SflIC; REGISTER NO. WARD NO. Der. of Birth; RfI"k!G'lJd••) CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 800 (REV. 6-97) Prescribed by GSAJlCMR FIRMR (41 CFR) 201-9.202.1 USAPPC VI.DO FOR OFFICIAL USE ONLY LAW ENFORCEi\IENT USE ONLY EXHIBIT~ MEDCOM -728 DOD 003791 U180-04-CID2S9-80227 STATUS CSPITA~ OR MEOICA~ FACILITY DEPART-ISERVICE SSNIID NO_ RE~ATIONSHIP TO SPONSOR PONSOR?S NAME .... TIENnS IDENTIFICATION IFor l'Iptfd or wrilten .ntrie$, giv.: Namll -last. fi,st, middle; /D No or SSN; S.,,; Der. 01 Birth: fgnklGrllll•.J REGISTER NO. WARD NO. rb)(6)-4 CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 800 IREV.6-97) Preacrlbed by GSAIICMR FIRMR (41 CFR) 201.9.202.' USAPPC V1.00 FOR OFFICIAL USE ONLY LAW ENFORCEMENT USE ONLY EXHIBIT t 1:. ~'" ~. Y" ~. MEDCOM -729 DOD 003792 01S0-04-CID259-S0227 - ~TIENTIS IDENTIFICATION (For ryptld or wrirren "ncrl,,!!, giv,,: N_mtl· IlIsr, (irsr, middl,,; 10 No 01 SSN; 5"11; REGISTER NO. WARD NO. Oat. of Bi,rh; fI"nlr/Gr.d•.J CHRONOLOGICAL ReCORD OF MEDICAL CARE Medical Record STANDARD FORM 600 IREV. 8-971 Prucrlbed by GSAJlCMR FIRMR (41 CFR,201-9.202-1 USAPl'CV1.00 • I;' , FOR OFFICIAL USE ONLY ~f l.! } LAW ENFORCEMENT USE ONLY EXHIBIT ~ / MEDCOM -730 DOD 003793 01S0-04-CID2S9-80227 ---_.--_." - I ~~~[/£) -­----­ ~ b)(6)-2 ~ ~ __/-fl!!7L ~ .... ---------____-------.~:;:;_;:::_----_r.:~~;::;:_::::_:::;:_----_r:==_:_:__:_:_::_-_:_~-­ ," i C" :.». MHllCAl FAClll~'y STr, TIJ:': D~PAR7./SERVIC~ RECCcROS MAINT.o,INEl) AT 155"11101;C. RELATIONSIJ!" TO SPONSOR I va;S'-IO-E-N-TiF-IC-A-n-ON-~(Fo-r-~-p""'-:-or-w-rt-:-·rre-n-.,,-"-;..-Sc-fJl-·~•..I.:'":"N~"m--.---:-III$-rc-:fi:-rsr-c""d(iI~; ID No 0' 55"'; 5t1x; IREGISTER NO. IWARO NO. /HI. of Birth; Ren#;/Gredo.1 __ CHRONOLOGICAL RECORD OF MEDICAl CARE Medical Record STANDARD FORM 8OO.1REV.1S-971 Pracribed by GSAIICMR FIRMR 1041 CFR) 201-9.202.1 USAPPC 111.00 FOR OFFICIAL USE ONLY EXHIBIT., LAW ENFORCEMENT USE ONLY / MEDCOM -731 ---_.... I DOD 003794

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3346
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72