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Patient Information Report
  --- Provided by Intake Solutions, Inc. ---

Here is your printable report (1 changes made, saved for future use):

Smith, John L. -- last updated 03/30/2017
Patient Name:   Smith, John L.   DOB: 12/07/1941   Last updated: 03/30/2017
SSN:   123-45-6789  
Sex:   M  
Marital:   Married  
Street:   904 Maple Ave SW  
City:   Romney  
State:   WV  
Zip:   24746-9998  
Phone:   304-555-2244  
Email Addr:   jsmith433@yahoo.com  
Spouse/Nok:   Kathy Smith (spouse); same addr; 304-555-2245  
PCP:   David Cohen; 304 Main St, #D / Romney, WV 20036-8132; 304-555-1205  
Overview:   -- Generally healthy senior male; blood type O+
-- migrain headaches, about once a week
-- arthritis in left elbow
-- hypertension
-- elevated cholesterol  
Drugs Used:   -- aspirin (2 reg), when migrains occur
-- moderate alcohol use (3 beers/week)
-- lisinopril/hctz (10/12.5mg) once/day for high BP  
Alergies:   -- pollen
-- bee stings
-- sulfa drugs
-- more ** 
Family History:   -- Type 2 diabetes, mother and her sister
-- Multiple Myeloma, father died at age 51  
Medicare #:   123-45-6789-T  
Medicaid #:    
Primary Ins:   Aetna; PO Box 1489 / Lexington, KY 40512-4089; 1-888-555-3862  
Prim Policy #:   W1086 11644-01  
Prim Type:   PPO  
Primary Owner:   self  
Employer:   CSC; 12000 Willard Dr / Chantilly, VA 22170-2218; 703-555-3000  
Secondary Ins:    
Sec Policy #:    

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