Henry Levin the 7th Good Health Clinic Dr.RobertDolin Good Health Clinic Good Health Clinic Good Health Clinic Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 Kenneth Ross Henrietta Levin Dr.RobertDolin Good Health Clinic

Transfer of care

Payer name	Policy type / Coverage type	Covered party ID	Authorization(s)
Good Health Insurance	Extended healthcare / Self	14d4a520-7aae-11db-9fe1-0800200c9a66	Colonoscopy

Good Health Insurance

Directive	Description	Verification	Supporting Document(s)
Resuscitation status	Do not resuscitate	Dr. Robert Dolin, Nov 07, 1999	Advance directive

Functional Condition	Effective Dates	Condition Status
Dependence on cane	1998	Active
Memory impairment	1999	Active

Condition	Effective Dates	Condition Status
Asthma	1950	Active
Pneumonia	Jan 1997	Resolved
"	Mar 1999	Resolved
Myocardial Infarction	Jan 1997	Resolved

Father (deceased)

Diagnosis	Age At Onset
Myocardial Infarction (cause of death)	57
Hypertension	40

Mother (alive)

Diagnosis	Age At Onset
Asthma	30

Social History Element	Description	Effective Dates
Cigarette smoking	1 pack per day	1947 - 1972
"	None	1973 -
Alcohol consumption	None	1973 -

1 pack per day None None

Substance	Reaction	Status
Penicillin	Hives	Active
Aspirin	Wheezing	Active
Codeine	Nausea	Active

Medication	Instructions	Start Date	Status
Albuterol inhalant	2 puffs QID PRN wheezing		Active
Clopidogrel (Plavix)	75mg PO daily		Active
Metoprolol	25mg PO BID		Active
Prednisone	20mg PO daily	Mar 28, 2000	Active
Cephalexin (Keflex)	500mg PO QID x 7 days (for bronchitis)	Mar 28, 2000	No longer active

Good Health Clinic Albuterol inhalant Clopidogrel Plavix Metoprolol Prednisone Cephalexin Keflex

Supply/Device	Date Supplied
Automatic implantable cardioverter/defibrillator	Nov 1999
Total hip replacement prosthesis	1998
Wheelchair	1999

Good Health Prostheses Company

Vaccine	Date	Status
Influenza virus vaccine, IM	Nov 1999	Completed
Influenza virus vaccine, IM	Dec 1998	Completed
Pneumococcal polysaccharide vaccine, IM	Dec 1998	Completed
Tetanus and diphtheria toxoids, IM	1997	Completed

Influenza virus vaccine Influenza virus vaccine Pneumococcal polysaccharide vaccine Tetanus and diphtheria toxoids

Date / Time:	Nov 14, 1999	April 7, 2000
Height	177 cm	177 cm
Weight	86 kg	88 kg
Blood Pressure	132/86 mmHg	145/88 mmHg

	March 23, 2000	April 06, 2000
Hematology
HGB (M 13-18 g/dl; F 12-16 g/dl)	13.2
WBC (4.3-10.8 10+3/ul)	6.7
PLT (135-145 meq/l)	123*
Chemistry
NA (135-145meq/l)		140
K (3.5-5.0 meq/l)		4.0
CL (98-106 meq/l)		102
HCO3 (18-23 meq/l)		35*

M 13-18 g/dl; F 12-16 g/dl

Procedure	Date
Total hip replacement, left	1998

Encounter	Location	Date
Checkup Examination	Good Health Clinic	Apr 07, 2000

Checkup Examination Good Health Clinic

Planned Activity	Planned Date
Pulmonary function test	April 21, 2000