CCD Generation 98685 Elm St Seattle WA 98595 US Dear Amber Archer 8 Fallen Oaks Drive, POB3141 Thousand Oaks CA 91360 US Cobb B Able Jr. Constant Family Care 2401 4th Avenue Suite #700 Seattle WA 98121 US 2401 4th Avenue Suite #700 Seattle WA 98121 US Cobb B Able Jr. Constant Family Care 2401 4th Avenue Suite #700 Seattle WA 98121 US 98685 Elm St Seattle WA 98595 US Mr. Gus Archer 2401 4th Avenue Suite #700 Seattle WA 98121 US Cobb B Able Jr. Constant Family Care 2401 4th Avenue Suite #700 Seattle WA 98121 US
purpose Request for Encounter
Problems
Problem Effective Dates Problem Status Note
DIVERTICULITIS SM Thursday, August 20, 2009 Active
ACUTE OTITIS MEDIAACUTE OTITIS MEDIA Monday, February 1, 2010 Active
OBSESSIVE COMPULS Thursday, February 18, 2010 Active
Allergies and Adverse Reactions
Substance Type Reaction Severity Dates Status
MARKALLERGY Drug Allergy Active
PENISILIAN Drug Allergy Active
MARKALLERGY PENISILIAN
Medication
Medication Instructions Refills Date Provider Note
ABREVA APP AA 10 % APP AA APP AA q5xd TOPICAL; APP AA 5XD TOPICAL 1 Monday, July 2, 2012
RISPERDAL TAB 1 TAB twice daily Oral; 1 TAB BID ORAL 12 Monday, July 2, 2012
ABREVA APP AA 10 % RISPERDAL
Insurance
Carrier Name Plan ID Policy Number Group # Insured's Name Relation Effective Dates
BLUE CROSS BLUE SHIELD 493938U484 Archer, Amber Self Tuesday, July 13, 2004
5267 Shady LaneBellevueWA98117US BLUE CROSS BLUE SHIELD 5267 Shady LaneBellevueWA98117US 98685 Elm StSeattleWA98595-US AmberArcher 98685 Elm StSeattleWA98595US DearAmberArcher
Advance Directives No advance directives included in this record None
Procedures
Description Procedure Provider Service Date Note
REMOVE/TREAT LUNG 32141 (CPT-4) Monday, July 2, 2012 at 3:08:00 pm
2401 4th Avenue Suite #700 Seattle WA 98121 US Cobb B Able Jr.
Immunization
Vaccine Date Status Dose Route Site Comment
INFLUENZA VACCINE Tuesday, April 6, 2004 at 6:20:00 pm Done Unknown
INFLUENZA VACCINE