Date: 11-27-2010 Patient Name: Demo Kate DOB: 01-01-1986 Address: Rendering Provider: Borne Jason Reason for

Visit: Eye strain Subjective Allergies General Allergy Allergy Name Type: Severity Degree Reaction Start Date Notes House Dust (Greer Labs) Dust Mild 10 R 11-27-2010 N Gender: Female Age: 25 Years

Allergy Name Type: Severity Degree Reaction Start Date Notes

Mite D.Farinae Dust Mites Severe 50 R 11-27-2010 N

Allergy Name Type: Severity Start Date Past Medical History Past Surgical History Patient denies history of Aortic Aneurysm surgery Patient denies history of Bladder augmentation surgery Cystduodenostomy Since: 12-06-2010 Note: asdf Embolization Since: 12-06-2010 End Date: 12-06-2010 Social History Birth Conditions

Apple Food Mild 12-02-2010

Born in the US: No Raised By A Single Parent: Mother Monetary Conditions: as Place Of Birth: as Substance abuse Do you have smokers at home?: >3 Smoking Status: Current some day smoker Objective

Review of System Gastrointestinal Patient denies: Vomiting blood or food, Cramping, Nausea, Reflux, GERD, Heart burn or indigestion, Abdominal Pain, Vomiting, Hemorrhoids, Bleeding, Constipation, Diarrhea

Assessment Plan Plan Notes Lab Order C3 Diagnostic/Lab orders C3 C-peptide C-Reactive Protein Factor IX Activated Activity Radiation Therapy Yeast - Urine Sediment Bacterial Culture - Urine 1,25 dihydroxy-vitamin D

Order Date: 11-27-2010 Order Date: 11-27-2010 Order Date: 11-27-2010 Order Date: 11-29-2010 Order Date: 11-29-2010 Order Date: 11-29-2010 Order Date: 11-29-2010 Order Date: 12-15-2010

Borne Jason This form has been electronically signed on 11-27-2010.

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