2026 Consolidated CDA

ALLERGIES AND ADVERSE REACTIONSNo Known Drug AllergiesNo Known Drug Allergies

MEDICATIONSMedication Start Date Directions Status

ketorolac 10 mg tablet, [RxNorm: 861844]
02/04/2019
1 TABLET BY MOUTH EVERY 4-6 HOURS AS NEEDED
Active
cyclobenzaprine 10 mg tablet, [RxNorm: 828350]
12/12/2018
1 tablet by oral 3 times per day as needed
Active
tramadol 50 mg tablet, [RxNorm: 152961]
12/12/2018
1 tablet daily by mouth as needed
Active
ondansetron 4 mg disintegrating tablet, [RxNorm: 876690]
12/12/2018
TAKE 2 TABLETS (8 MG) AND PLACE ON TOP OF THE TONGUE WHERE THEY WILL DISSOLVE, MAY REPEAT DOSE EVERY
ActivePROBLEMSNo known health problemsENCOUNTERSEncounter Performer Location Date

LIMITED NEW PT
Melodye Harvey
Auburn Montgomery Warhawk Health Services
Dec 12, 2018
INTERMEDIATE EST PT
Melodye Harvey
Auburn Montgomery Warhawk Health Services
Feb 04, 20197461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health ServicesPROCEDURESProcedure Date

UA, [CPT-4: 81003]
12/12/2018
UA, [CPT-4: 81003]
02/04/2019
THERAPEUTIC INJECTION ADMIN, [CPT-4: 96372]
02/04/20197461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US

            MEDICAL EQUIPMENTPatient has no history of implantable devicesIMMUNIZATIONSName Date Status

MMR
06/08/1985
Completed
TDap
02/18/2019
Completed
TDap
02/18/2019
CompletedMMR7461 East DrMontgomeryALUSMelodyeHarveyCRNPAuburn Montgomery Student Health Services7461 East DrMontgomeryAL36117USTDapu6141ABSanofi Pasteu7461 East DrMontgomeryALUSMelodyeHarveyCRNPAuburn Montgomery Student Health Services7461 East DrMontgomeryAL36117USTDapU6141ABSanofi Pasteu7461 East DrMontgomeryALUSMelodyeHarveyCRNPAuburn Montgomery Student Health Services7461 East DrMontgomeryAL36117USVITAL SIGNSDate Height Weight BMI Blood Pressure Temperature Pulse Pulse Oximetry Respiratory Rate Inhaled Oxygen Concentration Head Circumference Percentage BMI Percentage Weight to Length Percentage

12/12/2018 116/75 mm[Hg] 36 Cel 64 bpm
02/04/2019 99/64 mm[Hg] 65 bpmRESULTSResult Type Result Value Date

Leukocytes-Urine
Negative
12/13/2018
Leukocytes-Urine
Negative
02/04/2019
Urobilinogen-Urine
Negative
12/13/2018
Urobilinogen-Urine
Negative
02/04/2019
Protein [Mass/Volume] in Urine by Test strip
Negative mg/dL
12/13/2018
Protein [Mass/Volume] in Urine by Test strip
Negative mg/dL
02/04/2019
pH of Urine by Test strip
5 [pH]
12/13/2018
pH of Urine by Test strip
5 [pH]
02/04/2019
Blood-Urine
Negative
12/13/2018
Blood-Urine
Positive
02/04/2019
Ketones [Mass/Volume] in Urine by Test strip
Negative mg/dL
12/13/2018
Ketones [Mass/Volume] in Urine by Test strip
Negative mg/dL
02/04/2019
Glucose [Mass/Volume] in Urine by Test strip
Negative mg/dL
12/13/2018
Glucose [Mass/Volume] in Urine by Test strip
Negative mg/dL
02/04/2019
Specific Gravity of Urine by Test strip
1.000
12/13/2018
Specific Gravity of Urine by Test strip
1.010
02/04/2019
Bilirubin-Urine
Negative
12/13/2018
Bilirubin-Urine
Negative
02/04/2019
Nitrites-Urine
Negative
12/13/2018
Nitrites-Urine
Negative
02/04/2019
Appearance of Urine
Clear
12/13/2018
Appearance of Urine
Clear
02/04/2019
Color of Urine
Yellow
12/13/2018
Color of Urine
Yellow
02/04/2019NegativeNegativeNegativeNegativeNegativeNegativeNegativePositiveNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeClearClearYellowYellowPLAN OF TREATMENTNo Treatment Plan Defined Goals SectionNo goal informationHealth Concerns SectionNo Known Health Concerns on INSTRUCTIONSNo Known Instructions/Patient EducationSOCIAL HISTORYNo Social History Selected to be DisplayedFUNCTIONAL STATUSNo informationMENTAL STATUSNo information

Medication	Start Date	Directions	Status
ketorolac 10 mg tablet, [RxNorm: 861844]	02/04/2019	1 TABLET BY MOUTH EVERY 4-6 HOURS AS NEEDED	Active
cyclobenzaprine 10 mg tablet, [RxNorm: 828350]	12/12/2018	1 tablet by oral 3 times per day as needed	Active
tramadol 50 mg tablet, [RxNorm: 152961]	12/12/2018	1 tablet daily by mouth as needed	Active
ondansetron 4 mg disintegrating tablet, [RxNorm: 876690]	12/12/2018	TAKE 2 TABLETS (8 MG) AND PLACE ON TOP OF THE TONGUE WHERE THEY WILL DISSOLVE, MAY REPEAT DOSE EVERY	Active

Encounter	Performer	Location	Date
LIMITED NEW PT	Melodye Harvey	Auburn Montgomery Warhawk Health Services	Dec 12, 2018
INTERMEDIATE EST PT	Melodye Harvey	Auburn Montgomery Warhawk Health Services	Feb 04, 2019

Procedure	Date
UA, [CPT-4: 81003]	12/12/2018
UA, [CPT-4: 81003]	02/04/2019
THERAPEUTIC INJECTION ADMIN, [CPT-4: 96372]	02/04/2019

Name	Date	Status
MMR	06/08/1985	Completed
TDap	02/18/2019	Completed
TDap	02/18/2019	Completed

Date	Height	Weight	BMI	Blood Pressure	Temperature	Pulse	Pulse Oximetry	Respiratory Rate	Inhaled Oxygen Concentration	Head Circumference Percentage	BMI Percentage	Weight to Length Percentage
12/12/2018	116/75 mm[Hg]	36 Cel	64 bpm
02/04/2019	99/64 mm[Hg]	65 bpm

Result Type	Result Value	Date
Leukocytes-Urine	Negative	12/13/2018
Leukocytes-Urine	Negative	02/04/2019
Urobilinogen-Urine	Negative	12/13/2018
Urobilinogen-Urine	Negative	02/04/2019
Protein [Mass/Volume] in Urine by Test strip	Negative mg/dL	12/13/2018
Protein [Mass/Volume] in Urine by Test strip	Negative mg/dL	02/04/2019
pH of Urine by Test strip	5 [pH]	12/13/2018
pH of Urine by Test strip	5 [pH]	02/04/2019
Blood-Urine	Negative	12/13/2018
Blood-Urine	Positive	02/04/2019
Ketones [Mass/Volume] in Urine by Test strip	Negative mg/dL	12/13/2018
Ketones [Mass/Volume] in Urine by Test strip	Negative mg/dL	02/04/2019
Glucose [Mass/Volume] in Urine by Test strip	Negative mg/dL	12/13/2018
Glucose [Mass/Volume] in Urine by Test strip	Negative mg/dL	02/04/2019
Specific Gravity of Urine by Test strip	1.000	12/13/2018
Specific Gravity of Urine by Test strip	1.010	02/04/2019
Bilirubin-Urine	Negative	12/13/2018
Bilirubin-Urine	Negative	02/04/2019
Nitrites-Urine	Negative	12/13/2018
Nitrites-Urine	Negative	02/04/2019
Appearance of Urine	Clear	12/13/2018
Appearance of Urine	Clear	02/04/2019
Color of Urine	Yellow	12/13/2018
Color of Urine	Yellow	02/04/2019