200706111856522 English V1.0 2007-06-11T18:56:52-09:00 PATIENT_1010 PATIENT_1010 Patient ASD Patient Registration PAYER_1 Subscriber Number 111223333 PATIENT_1010 Primary Health Insurance PATIENT_1010 INSUR_1Payer PATIENT_1010 PAYER_2 Secondary Health Insurance PATIENT_1010 INSUR_2Payer PATIENT_1010 EMG1 Emergency Contact#1 MOTHER Mother PR21010 Onset 2007-06-11T00:00:00-09:00 Diagnosis Abdominal pain 789.0 ICD-9CM Active ASD PR31010 Onset 2007-06-11T00:00:00-09:00 Diagnosis Headache 784.0 ICD-9CM Active ASD FHX41010 Date of Birth 1949-03-03 Date of Death 2002-02-02 Condition Father, Fred Doe, born on 3/3/1949, died on 2/2/2002 at age 53; cause of death: CHF. Positive for Arthritis, Asthma, Hypertension and Obesity. Negative for Heart Attack. Active PATIENT_1010 Father PATIENT_1010 SHXR51010 Religion Catholic PATIENT_1010 SHXRA61010 Race White PATIENT_1010 SHXLA71010 Primary Language English PATIENT_1010 SHXCI81010 Citizenship USA PATIENT_1010 SHXBP91010 Birthplace Pasadena, CA PATIENT_1010 SHXDE101010 Highest Degree HS Diploma PATIENT_1010 AL111010 Onset 2007-06-11T00:00:00-09:00 Allergy Grass, Pollen, Trees Active ASD runny nose, watery, red eyes Meds12 2007-06-03 2007-06-03 Medication Active MM Prescriber LASIX 40 mgs

tablets

30 bid po with water every morning 1 IM131010 Immunization Date 1970-01-06T00:00:00-09:00 Immunization PATIENT_1010 Hepatitis B IM141010 Immunization Date 1970-01-15T00:00:00-09:00 Immunization PATIENT_1010 DTaP/DTP IM151010 Immunization Date 1970-01-15T00:00:00-09:00 Immunization PATIENT_1010 Hepatitis B IM161010 Immunization Date 2007-06-03T00:00:00-09:00 Immunization PATIENT_1010 Influenza RS171010 2007-06-11T18:52:00-09:00 VitalSigns PATIENT_1010 RST181010 Observation TEMPERATURE PATIENT_1010 98.6 F RSW191010 Observation WEIGHT PATIENT_1010 135 lb RSH201010 Observation HEIGHT PATIENT_1010 62 in RSBPS211010 Observation BP SYS PATIENT_1010 110 mmHg Sitting Right Arm RSBPD221010 Observation BP DIAS PATIENT_1010 70 mmHg Sitting Right Arm BMI231010 Observation BMI PATIENT_1010 24.69 BSA241010 Observation BSA PATIENT_1010 1.64 m^2 ASD Primary Care Provider> PATIENT_1010 John Martin Doe 1970-01-02 Male Patient Acct# 1010 PATIENT_1010 SecurityNumber 111-22-3333 PATIENT_1010 Driver License 123456 CA PATIENT_1010

Home 12 Main Street Los Angeles CA USA 90024

310-555-1234 Home Phone 310-555-3456 x11 Work Phone 310-555-2345 Cell Phone 310-555-5678 Pager 310-555-6789 Other Phone PATIENT_1010 ASD Abbey S. Duck MD Family/General Practice

Office 20140 Scholar Drive, Suite 316 Martinsburg WV 25401

PATIENT_1010 MM Mickey M. Mouse Family/General Practice

Office 34 Disney Lane Liverpool NY 13090

PATIENT_1010 INSUR_1 Blue Shield Federal Primary Insurance

Business 233 Iron Street Liverpool NY 13090

315-555-2222 Business 315-555-3333 Eligibility 315-555-4444 Authorization PATIENT_1010 INSUR_2 Empire of Upstate NY Secondary Insurance

Business 44 Route 23 Liverpool NY 13088

315-555-9876 Business 315-555-8765 Eligibility 315-555-7654 Authorization PATIENT_1010 MOTHER Marh Jane Doe 1950-02-02 SecurityNumber 222-33-4444 PATIENT_1010 Driver License 34567 PATIENT_1010 Mother

Home 12 Main Street Los Angeles CA 90024

310-555-9999 Home Phone 310-555-7777 x23 Work Phone 310-555-8888 Cell Phone 310-555-5555 Pager PATIENT_1010 EMG1 Sam Smith Neighbor

Home 14 Main Street Los Angeles, CA 90024

310-555-4545 Home Phone 310-555-2929 Work Phone 310-555-2323 Cell Phone PATIENT_1010 PracticeToday Practice Today Office Management System EHR 07.06 Serial# PracticeToday

Mailing Address POB 881705 Los Angeles CA USA 90009

888-881-0038 Business Phone support@practicetoday.com Support Desk PracticeToday