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File: 092496_aug96_decls4_0011.txt
Subject: PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91
Unit: ARCENT
Parent Organization: CENTCOM
Box ID: BX000460
Folder Title: MEDSTAT- SITREPS - JANUARY - 1
Document Number: 10
Folder SEQ #: 2
16:15:56 ftwiv PATIEN7 FILE H" 01/04/91
PMMXX DATA - PRIVACY ACT CZ 1974
5 U.S.C. 552 (b)(6)
13. MODE: A
1. NAME - 18. ALR@RITY #: 03blAO12 2. SSA4: 3. P CE: R
4. STAT- All 3. MUE- EOB 6. AGE: 3BY 7. SEX: M S. WT: 162 9. READY DATE: 361
!O. ISO: 11. PGR.- 12. SPEC CAT-.
,4. REAS RES: DS 15. DATE LAST VISIT: 16. @: 3A
17. ACCEPT PHYS: Mg 19. APPT/SURG DATE: NO
20. APPROV AUTH* 21. CfLV@/lh'C: 22. VALIDI LK< Y6
23. MV ORIG. A5150 LISA DISPENSARY DYAWM 24. ICAO CRIS: OEDR
25. MTF DEST: A5040 2ND GEN HOSP LANMTLWL. 26. ICAO DEST: EDAR
27. MED SPEC Is IN 28. DIAS 1: 7840 W"CHE
')9. MED SPEC 2: 30. DIAG 2:
31. MED SPEC 3., 32. DIAS 3:
32A. PROCEDURE:
. IV:
35. 02/LPH: N 36. SLr6T: N 37. NG TUBE: N 38. RESP: N 39. F@: N 40. STRYKER: N
41. INDB: N 42. TFW@T: N 43. IMED: N 44. CAST/LOC. N 45. TRADI: N 46. MON: N
71. PT BAB TYPR: NB 72. PT BAG TAG 73. PT BAG WT.
47. SU?P INFO: ME ABN CCRP,, FT. CAF@PBELL, KY REPORTED BY
OC@cC-RT/SUB AREA
48. ?AX Ek@ SMPS.- Y / 9 49. MAX # RO\'S: Y 9 50. ALT REST/FAX HI: N
53. INPATIENTs Y 54. SPEC PROS: VA DRUB ALCOHOI@ Wr NOE X 55. VA CODE:
@6. AD.IIN/OVERSEAS:
58. VITA. SIGNS(TEMP/PLIHJRESP/KMD PRESS): 097.3 / 84 16 / 120 60
59. HEB. 60. FCT: 61. ABGO I DATE Tka:
62. WBC.- 63. SI/VSI: 64. MEDICATIONS: L 40MG TID/TYLENOL 2TABS 04H
PR4/ELAVIL 75MG M.
65. HISTCRY: PT (IRIBIK4LLY DIAS\'OSED WITH INTRACTABLE HEADACHES IN MID-NOVEW.
PT EVALUATED AT 47TH FIELD HOSPITAL; TRA.ISFEMB M COMFORT FOR NEURMICAL
EMLOSIST FEELS PT NEEDS FURTU EVAI@ AND TX GLTT OF THE ACR.
66. ATT PHYS: CAPT M 67. PHI: 000 000 0000 68. KA.U#/PH#: 000 / 000 000 DODO
69. REPORTED BY: DaiTO.N 70. PHI: 000 0000
75. STATUS: 76. GRADE:
77. A6E- 78. SEX: 78A. WT: 79. RELATIONSHIP TO PATIENT:
eO. BAG TYPE: 81. BAG TAG 82. BAB @'T:
83. ATTENDi%lg NkC- #2: 84. STATUS: 85. GRADE:
66. AGE: 87. SEX: Er7A. 6T: 88. RELATIONSHIP M PATIENT-
69. BAG TYPE: 90. BAB TAG 91. BAG WT:
92. TRANS C.IIG PHONE EXT:
93. TRANS DEST PHONE EXT:
94. ETA QIIG KTF(DATF/TIME).- 000 95. ETA DEST KrF(DATE/Tlrt): 000
97. OTHER 00,@ :
n .@'i #: 0000/30 52. RON LO-@:
57. VALIDATED BY/REAS FOR HI M PRECEDENCE.
96. AIRCRAFT ITINERARY:
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Document 31 f:/Week-31/BX000460/MEDSTAT- SITREPS - JANUARY - 1/personal data privacy act of 1974 4 jan 91:09209615580712
Control Fields 17
File Room = aug96_declassified
File Cabinet = Week-31
Box ID = BX000460
Unit = ARCENT
Parent Organization = CENTCOM
Folder Title = MEDSTAT- SITREPS - JANUARY - 1
Folder Seq # = 2
Subject = PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91
Document Seq # = 12
Document Date =
Scan Date =
Queued for Declassification = 01-JAN-1980
Short Term Referral = 01-JAN-1980
Long Term Referral = 01-JAN-1980
Permanent Referral = 01-JAN-1980
Non-Health Related Document = 01-JAN-1980
Declassified = 20-SEP-1996