<html xmlns:myObj="urn:ms-kb"> <head> <META http-equiv="Content-Type" content="text/html; charset=utf-16"> <title>John Doe Medical History </title> </head> <body> <font face="Arial Narrow" size="1"> <table id="table1" bordercolor="black" cellspacing="0" cellpadding="1" width="500" align="center" border="5" height="132"> <tr> <td align="center"> <strong>DISCLAIMER</strong> </td> </tr> <tr> <td> <p> THE INFORMATION PROVIDED HERE IS CONFIDENTIAL AND SHOULD ONLY BE SHARED WITH THE OWNER'S EXPRESSED PERMISSION. IT IS IMPORTANT THAT THE USER SEEK THE ADVICE AND COUNSEL OF MEDICAL PROFESSIONALS. </p> </td> </tr> </table> <hr> <p align="left"> <font face="Arial" size="2"> <p><a href="how_does_it_work.php">Click here to return to How it works </a></p> <b>FILE CREATED ON: </b>Tuesday, March 31, 2009</font> </p> <a name="Main"> </a> <font face="Arial" size="3"> <p align="center"> <b>PERSONAL HISTORY</b> </p> </font> <table border="0" cellpadding="6"> <tr> <td width="16%"> <img border="0" src="JDOE.JPG" width="87" height="120"> </td> <td width="84%"> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2" colspan="4"> <p>Name <u>John Doe</u></p> </font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2" colspan="4"> <p>Medical Conditions <u>Diabetic, Asthma</u></p> </font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2"> <p> DOB <u>01-01-2001</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> Gender <u>Male</u></p> </font> </td> </tr> </table> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2" colspan="4"> <p>Address <u>12345 VISTA LINDA ST.</u></p> </font> </td> </tr> <tr> <td align="left" colspan="2"> <font face="Arial" size="2"> <p>City <u>San Antonio</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> State <u>TX</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p>Zip Code <u>78700</u></p> </font> </td> </tr> </table> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2"> <p>Phone Home <u>123-456-7890</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> Cell <u>123-333-3333</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> Work <u>123-444-4444</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> Fax <u>123-555-5555</u></p> </font> </td> </tr> </table> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2"> <p>Email Address <u>JDOW123@ISP.COM</u></p> </font> </td> </tr> </table> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2"> <p>Marital Status <u>Married</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p>Socio Economic <u>Employed</u></p> </font> </td> </tr> </table> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2"> <p>Occupation <u>Self Employed</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p>Hours <u>35</u></p> </font> </td> </tr> </table> <table border="0" cellpadding="3"> <tr> <td align="left"> <font face="Arial" size="2"> <p>Blood Type <u>O+</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> Height <u>6'1"</u></p> </font> </td> <td align="left"> <font face="Arial" size="2"> <p> Weight <u>190</u></p> </font> </td> </tr> </table> </td> </tr> </table> <br> <p align="center"> <font face="Arial" size="2"> <b>ALLERGIES/REACTIONS</b> </font> <table border="1" cellpadding="3" cellspacing="0" width="70%"> <tr> <td align="center" width="40%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Name of Allergen</b> </font> </td> <td align="center" width="60%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Describe Reaction</b> </font> </td> </tr> <tr> <td align="left" valign="top"> <font face="Arial" size="2">Penicillin</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Rashes, hives, itchy eyes and swollen lips or face.</font> </td> </tr> <tr> <td align="left" valign="top"> <font face="Arial" size="2">Latex</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Results in dryness, itching, burning, scalling and lesions of the skin.</font> </td> </tr> </table> </p> <p align="left"> <font face="Arial" size="3"> <b>Assistive Devices</b> </font> </p> <table border="0" cellpadding="0" cellspacing="0"> <tr> <td> <font face="Arial" size="2"> </font> </td> <td> <font face="Arial" size="2"> </font> </td> </tr> </table> <table border="0" cellpadding="0" cellspacing="0"> <tr> <td> <font face="Arial" size="2"> <ul> <li> Glasses</li> </ul> </font> </td> <td> <font face="Arial" size="2"> <ul> <li> Contact Lens</li> </ul> </font> </td> <td> <font face="Arial" size="2"> </font> </td> <td> <font face="Arial" size="2"> </font> </td> </tr> </table> <table border="0" cellpadding="0" cellspacing="0"> <tr> <td> <font face="Arial" size="2"> </font> </td> <td> <font face="Arial" size="2"> </font> </td> </tr> </table> <table border="0" cellpadding="0" cellspacing="0"> <tr> </tr> </table> <table border="0" cellpadding="0" cellspacing="0"> <tr> <td cellspan="3"> <font face="Arial" size="2"> <ul> <li>Other not shown: <u>Lower Left Leg Prosthesis</u></li> </ul> </font> </td> </tr> </table> <p align="left"> <font face="Arial" size="3"> <b>Living Arrangements</b> </font> </p> <table border="0" cellpadding="0"> <tr> <td> <font face="Arial" size="2"> <ul> <li>Living with Spouse: <u>Yes</u></li> </ul> </font> </td> <td> <font face="Arial" size="2"> <ul> <li>Spouse Name: <u>Jane Doe</u></li> </ul> </font> </td> <td> <font face="Arial" size="2"> <ul> <li>Phone: <u>210-555-5555</u></li> </ul> </font> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>COMMON HEALTH TESTS <br>AND PREVENTIVE HEALTH SCREENINGS</b> </font> </p> <table align="center" border="1" cellspacing="0" cellpadding="3" width="80%"> <tr> <td align="center" width="80%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>TEST</b> </font> </td> <td align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>DATE DONE</b> </font> </td> </tr> <tr> <td> <font face="Arial" size="2">Physical Exam</font> </td> <td align="center"> <font face="Arial" size="2">09/26/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Physical Exam</font> </td> <td align="center"> <font face="Arial" size="2">04/06/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Physical Exam</font> </td> <td align="center"> <font face="Arial" size="2">02/04/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Lipid Profile (Cholesterol)</font> </td> <td align="center"> <font face="Arial" size="2">02/29/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Eye Exam</font> </td> <td align="center"> <font face="Arial" size="2">02/04/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Hearing Exam</font> </td> <td align="center"> <font face="Arial" size="2">01/04/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Managing Diabetes</font> </td> <td align="center"> <font face="Arial" size="2">03/04/2008</font> </td> </tr> <tr> <td> <font face="Arial" size="2">Carotid Artery Check</font> </td> <td align="center"> <font face="Arial" size="2">02/12/2009</font> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>FAMILY HISTORY</b> </font> </p> <table align="center" width="80%" border="1" cellpadding="1" cellspacing="0"> <tr> <td align="center" bgcolor="#C0C0C0"> <b>Problem/Disease</b> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Alcohol Problems : NA</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Asthma : Father</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Bleeding Disorder : Father and Mother</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Cancer : Mother</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Depression : Sister</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Diabetes : Brother</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Glaucoma : Sister</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Heart Disease : Mother</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">High Blood Pressure : Father</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Lung Disease : NA</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Kidney Disease : Father</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Seizures : Mother</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Stroke : Sister</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Thyroid Disease : Brother</font> </td> </tr> </table> <br> <table align="center" border="0" cellpadding="0"> <tr> <td> <font face="Arial" size="2"> <b>Present age or age at death: </b> </font> </td> <td> <font face="Arial" size="2">Father <u>84</u></font> </td> <td> <font face="Arial" size="2">Mother <u>82</u></font> </td> </tr> </table> <table align="center" border="0" cellpadding="0"> <tr> <td> <font face="Arial" size="2"> <b>A member of my family or I has problems related to anesthesia: </b> <u>No </u> </font> </td> </tr> <tr> </tr> </table> <br> <p align="center"> <font face="Arial" size="3"> <b>SOCIAL HISTORY</b> </font> </p> <table width="80%" border="0" cellpadding="0" align="center"> <tr> <td> <table border="0" cellpadding="4"> <tr> <td> <b>Smoking : </b> <u>Yes</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b> Years of smoking : </b> <u>17 yrs</u> </td> <td> <b> How much : </b> <u>1 pack/day</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Other Forms of Tobacco : </b> <u>No</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Alcohol : </b> <u>Yes</u> </td> <td> <b> How much : </b> <u>1 or 2 glasses</u> </td> <td> <b> How Often : </b> <u>Socially</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Street Drugs : </b> <u>No </u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Excessive exposure to the sun because of work or recreation : </b> <u>NA</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Exercise : </b> <u>Yes</u> </td> <td> <b> Type : </b> <u>Golf and Walking</u> </td> <td> <b> How Often : </b> <u>3 times per week</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Restrictions Limitations : </b> <u>No</u> </td> </tr> </table> <table border="0" cellpadding="4"> <tr> <td> <b>Emotional Stress : </b> <u>No </u> </td> </tr> </table> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>QUICK REFERENCE GUIDE</b> </font> </p> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Primary Care Physician (PCP)</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Physician </b> <u>Dr. Richard Gonzalez</u> </td> <td width="30%"> <b>Phone </b> <u>210-509-2603</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Nurse </b> <u>Mary Davis</u> </td> <td width="30%"> <b>Phone </b> <u>210-509-2603</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u>7616 Culebra Rd., Suite 130</u> </td> <td width="30%"> <b>Fax </b> <u>210-553-0001</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78251</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Specialist</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="55%"> <b>Name </b> <u>Dr. Zeba Gil</u> </td> <td width="45%"> <b>Specialty </b> <u>Internal Medicine</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="60%"> <b>Address </b> <u>7616 Culebra Rd., Suite 130</u> </td> <td width="20%"> <b>Phone </b> <u>210-509-2603</u> </td> <td width="20%"> <b>Fax </b> <u></u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78251</u> </td> </tr> </table> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>QUICK REFERENCE GUIDE</b> </font> </p> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Specialist</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="55%"> <b>Name </b> <u>Dr. Manuel Martinez</u> </td> <td width="45%"> <b>Specialty </b> <u>Internal Medicine</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="60%"> <b>Address </b> <u>4212 E. Southcross, Suite 210</u> </td> <td width="20%"> <b>Phone </b> <u>210-333-3066</u> </td> <td width="20%"> <b>Fax </b> <u></u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78221</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Dentist</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Dentist </b> <u>Roger Levien, DDS</u> </td> <td width="30%"> <b>Phone </b> <u>210-343-4343</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u>1213 35th Street</u> </td> <td width="30%"> <b>Fax </b> <u>210-898-9999</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78249</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Dental Specialist</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Dental Specialist </b> <u>William Pruit, DDS</u> </td> <td width="30%"> <b>Phone </b> <u>210-437-9287</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="100%"> <b>Specialty </b> <u>Orthodontist</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u>3456 10th Street</u> </td> <td width="30%"> <b>Fax </b> <u>210-333-3336</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78225</u> </td> </tr> </table> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>QUICK REFERENCE GUIDE</b> </font> </p> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Hospital Information</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Hospital </b> <u>Christ Santa Maria</u> </td> <td width="30%"> <b>Phone </b> <u>210-767-7789</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u>1111 Medical Dr.</u> </td> <td width="30%"> <b>Fax </b> <u>210-346-7776</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78230</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="100%"> <b>Emergency Room Location </b> <u>1111 Medical Dr.</u> </td> </tr> <tr> <td width="100%"> <b>Directions </b> <u>IH-35 North, Exit 10th Street turn right to Medical Dr. got two blocks ahead.</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Pharmacy Information</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Pharmacy </b> <u>Your Pharmacy</u> </td> <td width="30%"> <b>Phone </b> <u>513-841-6620</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u>4500 Montgomery Rd.</u> </td> <td width="30%"> <b>Fax </b> <u>513-841-6621</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>Austin</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>45212</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="100%"> <b>Web Site </b> <u>www.yourpharmacy.com</u> </td> </tr> </table> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>QUICK REFERENCE GUIDE</b> </font> </p> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Health Insurance Information</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Company </b> <u>Union Career Health</u> </td> <td width="30%"> <b>Phone </b> <u>800-357-0978</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u>PO Box 740800</u> </td> <td width="30%"> <b>Fax </b> <u>210-478-4886</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>Atlanta</u> </td> <td width="20%"> <b>State </b> <u>GA</u> </td> <td width="30%"> <b>Zip Code </b> <u>30374</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>Policyholder's Name </b> <u>John Doe</u> </td> <td width="20%"> <b>Group # </b> <u>684587</u> </td> <td width="30%"> <b>Policy # </b> <u>934387189</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Dental Insurance</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Company </b> <u>Union Career Health Dental PPO</u> </td> <td width="30%"> <b>Phone </b> <u>210-478-4886</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="70%"> <b>Address </b> <u></u> </td> <td width="30%"> <b>Fax </b> <u></u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78250</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>Policyholder's Name </b> <u>Jane Doe</u> </td> <td width="20%"> <b>Group # </b> <u>605945539</u> </td> <td width="30%"> <b>Policy # </b> <u>4653329</u> </td> </tr> </table> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>QUICK REFERENCE GUIDE</b> </font> </p> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Primary Caregiver</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="60%"> <b>Name </b> <u>Jane Doe</u> </td> <td width="40%"> <b>Relationship </b> <u>Spouse</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="40%"> <b>Phone: Home </b> <u>123-456-7890</u> </td> <td width="30%"> <b>Cell </b> <u>123-333-3333</u> </td> <td width="30%"> <b>Other </b> <u></u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="80%"> <b>Address </b> <u>12345 VISTA LINDA ST.</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78700</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Emergency Contact #1</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="60%"> <b>Name </b> <u>Jane Doe</u> </td> <td width="40%"> <b>Relationship </b> <u>Wife</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="40%"> <b>Phone: Home </b> <u>512-677-7789</u> </td> <td width="30%"> <b>Cell </b> <u>512-888-9999</u> </td> <td width="30%"> <b>Other </b> <u>512-676-7777</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="80%"> <b>Address </b> <u>123 Main St.</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>Austin</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78700</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Emergency Contact #2</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="60%"> <b>Name </b> <u>Donald Doe</u> </td> <td width="40%"> <b>Relationship </b> <u>Brother</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="40%"> <b>Phone: Home </b> <u>512-766-6678</u> </td> <td width="30%"> <b>Cell </b> <u>512-645-6464</u> </td> <td width="30%"> <b>Other </b> <u></u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="80%"> <b>Address </b> <u>13514 Blake Street</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>San Antonio</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78249</u> </td> </tr> </table> </td> </tr> </table> <br> <table align="center" border="0" width="100%" style="border-style: solid"> <tr> <td width="100%"> <table align="center" bgcolor="#C0C0C0" border="0"> <tr> <td width="100%"> <p align="center"> <b>Clergy</b> </p> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="60%"> <b>Name </b> <u>Msgr. Patrick O'Brien</u> </td> <td width="40%"> <b>Affiliation </b> <u>Catholic</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="40%"> <b>Phone: Home </b> <u>512-667-8768</u> </td> <td width="30%"> <b>Cell </b> <u>512-809-0000</u> </td> <td width="30%"> <b>Other </b> <u></u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="80%"> <b>Address </b> <u>1234 Saint Rd.</u> </td> </tr> </table> </td> </tr> <tr> <td width="100%"> <table border="0" width="100%"> <tr> <td width="50%"> <b>City </b> <u>Austin</u> </td> <td width="20%"> <b>State </b> <u>TX</u> </td> <td width="30%"> <b>Zip Code </b> <u>78723</u> </td> </tr> </table> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>HEALTH HISTORY</b> </font> <br> <font face="Arial" size="2"> <b>CURRENT OR PAST ILLNESSES/MEDICAL CONDITIONS</b> </font> </p> <table align="center" border="1" width="100%" cellspacing="0"> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>GENERAL</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Fatigue </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>SKIN</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Rashes </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>HEAD</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Headaches </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>MENTAL</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Mood changes </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>EYES</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Redness </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>EARS</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Dizziness </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>NOSE/ SINUSES</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Sinus trouble </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>LUNGS</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Asthma </font> <font face="Arial" size="2"> *Allergies </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>KIDNEY - BLADDER</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Renal insufficiency </font> </td> </tr> <tr> <td width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>ENDOCRINE</b> </font> </td> <td width="70%"> <font face="Arial" size="2"> *Diabetes </font> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="2"> <b>SURGERIES/INJURIES/PROCEDURES</b> </font> <br> </p> <table align="center" border="1" cellpadding="0" cellspacing="0" width="100%"> <tr> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>DATE</b> </font> </td> <td align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>CONDITION/SURGERY/PROCEDURE</b> </font> </td> <td align="center" width="35%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>TREATMENT/COMMENTS</b> </font> </td> </tr> <tr> <td valign="top" align="center"> <font face="Arial" size="2">08/03/2007</font> </td> <td valign="top"> <font face="Arial" size="2">Heart Surgery</font> </td> <td valign="top"> <font face="Arial" size="2">Double Bypass</font> </td> </tr> <tr> <td valign="top" align="center"> <font face="Arial" size="2">05/01/2007</font> </td> <td valign="top"> <font face="Arial" size="2">Cataracts Surgery</font> </td> <td valign="top"> <font face="Arial" size="2">Eye Antibiotic, Eye drops</font> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>MEDICATIONS</b> </font> </p> <p align="center"> <font face="Arial" size="2"> <b>ROUTINE PRESCRIBED RX MEDICATION RECORD</b> </font> <br> </p> <table align="center" border="1" cellpadding="0" cellspacing="0" width="100%"> <tr> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date Start</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date Stop</b> </font> </td> <td align="center" width="21%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Prescribed By</b> </font> </td> <td align="center" width="15%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>RX</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Pharmacy</b> </font> </td> <td align="center" width="5%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>How Much</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>How Often</b> </font> </td> <td align="center" width="19%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Why Taking</b> </font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/23/2006</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">*</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Dr. Victor Gonzaba</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Diclofenac Sodium</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">H-E-B Pharmacy</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">75 mg</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Twice Daily</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Lower Back Pain</font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/25/2005</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">02/05/2007</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Dr. Bob Knight</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Lipitor</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">H-E-B Pharmacy</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">one pill</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Daily</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Cholesterol</font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/05/2007</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">02/25/2008</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Dr. Bob Knight</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">RXONE</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">H-E-B Pharmacy</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">5ml</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Every 8 hrs</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">High Cholesterol</font> </td> </tr> </table> <br> <p align="center"> <font face="Arial" size="2"> <b>OVER THE COUNTER MEDICATION RECORD</b> </font> <br> </p> <table align="center" border="1" cellpadding="0" width="100%" cellspacing="0"> <tr> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date Start</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date Stop</b> </font> </td> <td align="center" width="21%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Prescribed By</b> </font> </td> <td align="center" width="15%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>RX</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Pharmacy</b> </font> </td> <td align="center" width="5%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>How Much</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>How Often</b> </font> </td> <td align="center" width="19%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Why Taking</b> </font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/05/2007</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">*</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Dr. Charles Rockwood</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Claritin-D</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Walgreens</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">One Pill</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">When Needed</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Allergies</font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/05/2006</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">*</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Dr. Bob Knight</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Tylenol</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Walgreens</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">1 pill</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Every 6 hrs</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Headaches</font> </td> </tr> </table> <br> <p align="center"> <font face="Arial" size="2"> <b>OVER THE COUNTER (OTC) RECORD</b> </font> <br> <font face="Arial" size="2"> <b>Vitamins - Herbal/Folk Medicine - Dietary Supplements</b> </font> <br> </p> <table align="center" border="1" cellpadding="0" width="100%" cellspacing="0"> <tr> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date Start</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date Stop</b> </font> </td> <td align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>OTC Drug</b> </font> </td> <td align="center" width="16%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Pharmacy</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>How Much</b> </font> </td> <td align="center" width="10%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>How Often</b> </font> </td> <td align="center" width="24%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Why Taking</b> </font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/02/2006</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">*</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Centrum Silver</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Walgreens</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">3 pills</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Once after meal</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Calcium Deficiency</font> </td> </tr> <tr> <td align="center" valign="top"> <font face="Arial" size="2">02/02/2007</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">*</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Vitamin B</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">GNC</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">2 Pills</font> </td> <td align="center" valign="top"> <font face="Arial" size="2">Daily</font> </td> <td align="left" valign="top"> <font face="Arial" size="2">Health</font> </td> </tr> </table> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>ONGOING DIAGNOSTIC MONITORING DATA</b> </font> </p> <p> <font face="Arial" size="2"> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Weight</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">124</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">125</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">177</font> </td> <td align="center"> <font face="Arial" size="2">03/06/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">178</font> </td> <td align="center"> <font face="Arial" size="2">02/21/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">181</font> </td> <td align="center"> <font face="Arial" size="2">02/18/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">182</font> </td> <td align="center"> <font face="Arial" size="2">02/04/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Waist Measurement</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">36</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">34</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">34 1/2</font> </td> <td align="center"> <font face="Arial" size="2">06/01/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">35</font> </td> <td align="center"> <font face="Arial" size="2">04/05/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">35 1/2</font> </td> <td align="center"> <font face="Arial" size="2">02/04/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Temperature</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">98.7</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">98.6</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">98.7</font> </td> <td align="center"> <font face="Arial" size="2">04/13/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">98.8</font> </td> <td align="center"> <font face="Arial" size="2">03/05/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">98.6</font> </td> <td align="center"> <font face="Arial" size="2">02/04/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Pulse</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">63</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">60</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">61</font> </td> <td align="center"> <font face="Arial" size="2">04/11/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">61</font> </td> <td align="center"> <font face="Arial" size="2">03/10/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">63</font> </td> <td align="center"> <font face="Arial" size="2">02/03/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Blood Pressure</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">125/80</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">110/70</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">125/85</font> </td> <td align="center"> <font face="Arial" size="2">07/05/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">122/78</font> </td> <td align="center"> <font face="Arial" size="2">05/13/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">120/70</font> </td> <td align="center"> <font face="Arial" size="2">02/04/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Blood Pressure (Sitting)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">125/80</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">110/70</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">125/80</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Blood Pressure (Standing)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">125/80</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">110/70</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">125/80</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Blood Pressure (Lying)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">125/80</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">110/70</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">125/80</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Blood Sugar</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">130 mg/dl</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">100mg/dl</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">130 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">04/13/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">140 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">03/03/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">140 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">02/23/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Glycosylated Hemoglobin A1C</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">8</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">6</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">8</font> </td> <td align="center"> <font face="Arial" size="2">05/12/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">8</font> </td> <td align="center"> <font face="Arial" size="2">03/05/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">10</font> </td> <td align="center"> <font face="Arial" size="2">02/02/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Urine Protein </font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">7.6</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">6.0-8.0 g/dL</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">7.6</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">BUN</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">14</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">8-25 mg/dL</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">14</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Creatinine</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">1.1</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">0.6-1.5 mg/dL</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">1.1</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Total Cholesterol</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">200 mg/dl</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">&lt;200 mg/dl</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">190 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">04/13/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">210 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">02/03/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">High Density Cholesterol (HDL)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">50 mg/dl</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">&gt;39 mg/dl</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">60 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">06/12/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">50 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">03/13/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">40 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">02/05/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Low Density Cholesterol (LDL)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">130 mg/dl</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">&lt;100 mg/dl</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">110 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">05/12/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">120 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">03/12/2008</font> </td> </tr> <tr> <td align="center"> <font face="Arial" size="2">130 mg/dl</font> </td> <td align="center"> <font face="Arial" size="2">02/03/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Triglycerides </font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">52</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">&lt; 150 mg/dL</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">52</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Sodium (Na)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">140</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">135-145 mmo1/L</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">140</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Potassium (K)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">4.1</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">3.5-5.2 mmo1/L</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">4.1</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Carbon Dioxide (CO2)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">28</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">19-31 mmo1/L</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">28</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">White Blood Cells</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">7.8</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">4.0-11.0 k/mm3</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">7.8</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Red Blood Cells</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">5.14</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">4.30-6.00 m/mm3</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">5.14</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Hemoglobin (Hgb)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">15.8</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">13.0-18.0 g/dL</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">15.8</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Hematocrit (Hct)</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">45.7</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">40.0-53.0%</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">45.7</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Platelets</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">244</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">130-450 k/mm3</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2">244</font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> <table align="center" border="0" width="90%" cellspacing="0" style="border-style: solid"> <td width="70%" valign="top"> <table align="center" valign="top" border="1" cellspacing="0" width="100%" frame="box" rules="all"> <tr> <th align="center" width="55%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Data</b> </font> </th> <th align="center" width="25%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Base Line</b> </font> </th> <th align="center" width="20%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Goal</b> </font> </th> </tr> <tr> <td align="left" valign="bottom"> <font face="Arial" size="2">Eye Exam</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">20/20</font> </td> <td align="center" valign="bottom"> <font face="Arial" size="2">20/20</font> </td> </tr> </table> </td> <td width="70%" valign="top"> <table align="center" valign="top" cellspacing="0" border="1" width="100%" frame="box" rules="all"> <tr> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Result</b> </font> </th> <th align="center" width="50%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>Date</b> </font> </th> </tr> <tr> <td align="center"> <font face="Arial" size="2"></font> </td> <td align="center"> <font face="Arial" size="2">11/06/2008</font> </td> </tr> </table> </td> </table> </font> </p> <p align="center" style="page-break-before: always"> <font face="Arial" size="3"> <b>IMMUNIZATION RECORD</b> </font> </p> <table align="center" border="1" cellpadding="0" width="70%" cellspacing="0"> <tr> <th align="center" width="48%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>AGENT / VACCINATION</b> </font> </th> <th align="center" width="11%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>DATE DONE</b> </font> </th> <th align="center" width="11%" bgcolor="#C0C0C0"> <font face="Arial" size="2"> <b>DUE AGAIN</b> </font> </th> </tr> <tr> <td align="left"> <font face="Arial" size="2">Influenza (flu shot)</font> </td> <td align="center"> <font face="Arial" size="2">10/24/2007</font> </td> <td align="center"> <font face="Arial" size="2">10/01/2008</font> </td> </tr> <tr> <td align="left"> <font face="Arial" size="2">Hepatitis B vaccine (if needed)</font> </td> <td align="center"> <font face="Arial" size="2">02/12/2008</font> </td> <td align="center"> <font face="Arial" size="2">08/12/2008</font> </td> </tr> </table> <p><a href="how_does_it_work.php">Click here to return to How it works </a></p> </font> 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