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File: 102896_aug96_decls4_0019.txt
Subject: PATIENT FILE
Box ID: BX000482
Unit: ARCENT
Parent Organization: CENTCOM
Folder Title: MEDSTAT - SITREPS OCT 90 3 OF 4
Folder SEQ #: 16
Document Number: 11
O'@-,55:39 PATIP%I FILE 10,130190
PERSONAL DATA - PRTVA@@Y ACT OF 974
5 U.S.C. 552 (b)(6)
13. A
1. NAME: 18. AUTHORITY 2. SSAN: 3, PRECEDENCE: El
4. ST.AT; Ail 5. GRADET clo'_) 6. ACEI 21Y, 7. SEX; M S@ t-)T: 175 9. READY DATE: 302
10. ISO: It. POR- 11 1 12. SPEC @IAT:
14@ REAS AEG: Do' l@,@ DATE LAST V7SI,
16. P@LASS: 3A
17. ACCEPT PHY6: div,-RO 19@ APPT/SURG DATE:
20. APPROV ALITH,. 2i, @IANC/IN@l; 22. VAI@!DI I
27@ Vi-@,F ORTG: A51@@o USA DISPENSARY DPA.@'RA%l 24. !,PAD G@RIG: OEDR
5
,5. MTF DEST: @ 070 IJSAFR@(' 'WIESBADEN Bc 26. ICAD DEST; EDAF
27. MPD SPEC l@ AHE 28. DIAS 1: 38910 S'@NSORINEURAL HEARING LOSS, U@ISPECIF IED
29. ilc@D SPEP@ 2i 3f". DIAS 2:
31@ TIED SPEC 3@ 32, DIAG 3:
2A. PROCEDURE:
SPEC DIET: iN/ 34. IV: MI
35. 02/LP',4,: N 1 36@ G!JCT,. N' 37@ N"u TUBE; 36. RESPZ % FOLEY: @N 40. STRYKER: kl
41- !N'UUB: N 42. TRA@@TZ N 43. TMC@D: N 44. P,ASi/LGC: N 45. TRACH: N 46. MON: N
71, PT BAG TYPE: NB 72. PT BAD -,,AG 73. PT BAG @IT:
47. SUPP INFO: FT, I.EWIS, TX REPORTED BY
44T'j MED BGD./SGT 'HASSlt\'SER
I @,A
@S, MAX @@NRTE STOPS-. Y / 9 49. k' X @' RONS@ Y 9 @O. ALT RESTIMAX P.Ti I
5'@. lt\'PA7'.IEN@l: Y 54. SPEC PROS. VA DRUG ALCOHOL '4T NONE X 55. VA CODE-.
56. ADiNii,'/QVERSEAS:
58. VITAL Bl@uN'S(TCF,@P/PU@SE/REEP/BLCDD F.RESS)@ 099.0 080 20 130 060
DATE -, YEN@
@9a @.GB; 60. F,CT: 61. ADS: A
62@ 63. SI/VSI: 64. MEDICATIONS: NONE
PT-@T RY: PA.91- MEDICAL NX OF 'HEARING DEFICIENCY ALL OF LIFE. PATIENT WORKS A
3 A STE@!ASLO@RE. iNr DS EVAC FOR AUDIOLOGY. NO CAPABILITIES IN THE ADR.
PH#: 000 000 000 0000
69. REPORTED BY-. r.ARC4ANT 70. PH@: 000 0000
74. ATTENDANT NAME @tl 7o. STATUS: 76. GRADET
77@ AGE@ 78. Sclxt 78A. 'AT: 79. RELATIONSHIP TO PATIENT;
80. BAG TYPE: 81. BAG TAG 92. DAG @IT:
83. ATTENDANT NAME 4-2: 84. STATUS: 85@ GRADE:
86. AGE: 87. SEX: 87A. WT: 88. RELATIONSHIP TO PATIENT:
89. BAB lYDEi 90. BAB TAG #t 91. BAG WT:
92@ TRANS OFIG PHONE EX-1@@
93@ TRANS DEST PHONE EXT:
94, ETA CRIS MTF(DATE/T'L@'@.E)t 95, ETA DEST 'ITF(DATE/Tli%IE):
97. OTHER CO?iMPN-16@
51. @iSNi #: 00001302 52. RON LOP,:
57. VALIDATED BY/R@'AS FOR HISPER PRECEDENCE:
96. AIRCRAFT ITINERARY: I I I
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Document 31 f:/Week-32/BX000482/MEDSTAT - SITREPS OCT 90 3 OF 4/patient file:10019616503620
Control Fields 17
File Room = aug96_declassified
File Cabinet = Week-32
Box ID = BX000482
Unit = ARCENT
Parent Organization = CENTCOM
Folder Title = MEDSTAT - SITREPS OCT 90 3 OF 4
Folder Seq # = 16
Subject = PATIENT FILE
Document Seq # = 11
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 = 01-OCT-1996