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MAXICARE LIFE & HEALTH CO.
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LUCY POLAK, MD
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MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - PALMETTO GBA
MEGA LIFE & HEALTH INS COMP.
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MEDICARE- J1 MAC - PALMETTO GBA
SWA SOUTHWEST ADMINISTRATORS INC
MNUI
SHEET METALS WORKER LOCAL 206
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MEDICARE- J1 MAC - NORIDIAN
CHP HEALTH BENEFITS TRUST
ANDREW PARASHOS
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MEDICARE- J1 MAC - PALMETTO GBA
BLUE SHIELD OF CALIFORNIA
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Wells Fargo- Leave Processing
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MEDICARE- J1 MAC - PALMETTO GBA
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CMS(CI)
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MCAL-LA COMMUNITY HEALTH PLAN
SHARP CHULA VISTA EA
AMADEX
GOLDEN EAGLE
DO NOT USE
CARPENTERS HEALTH & WELFARE FUND
SHARP COMMERCIAL-INDEPENDENT
MEDICARE- J1 MAC - PALMETTO GBA
CCN-MOUNTAIN STATES ADM SVCS
EQUITABLE INS
BLUE CROSS PPO
UNITEDHEALTHCARE
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NAT ASSN OF LET CAR
UNITED FOOD & COMM
PGBA
CENTRAL VALLEY TRUST-BLUE CROSS
TRIWEST
CCN
BLUE CROSS OF CALIFORNIA
CHAMPVA
MEDICARE- J1 MAC - PALMETTO GBA
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SECURE HORIZONS
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MEDICARE- J1 MAC - NORIDIAN
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GREAT WEST & ANNUITY CO
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FIRST HEALTH
ONE HEALTH PLAN -HM
PERS CARE
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Mega Life Ins Company
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MEDICARE- J1 MAC - PALMETTO GBA
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HEALTHLINK
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MEDICARE- J1 MAC - PALMETTO GBA
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MEDICAID-OUT OF STATE
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HIGHMARK BLUE CROSS
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BLUE CROSS OF CA.
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ALLIANZ
MEDICARE- J1 MAC - PALMETTO GBA
CARE FIRST HEALTH PLAN- MEDI CAL
CONSECO SENIOR HELTH PLAN
PINNACLE CLAIMS MANAGEMENTIC
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LA VIDA MEDICAL GROUP & IPA
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MITSUI SUMITOMO
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KAISER-COMM
AZ BENEFIT OPTIONS-HARRINGTON
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SEDWICK CMS
WASHINGTON NATIONAL
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AMERICAN REPULIC INC
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SEDGWICK C M S ORANGE
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MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - NORIDIAN
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MEGAHEALTH & LIFE INSURANCE
MEDICARE- J1 MAC - PALMETTO GBA
ANTHEM BLUE
HEALTHNET
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CALOPTIMA EDS CROSSOVER UNIT
UMR
MEDICARE- J1 MAC - PALMETTO GBA
AMERICAN MEDICAL SECURITY
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WESTERN & SOUTHERN BENEFITS DEPA
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ILWU
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PACIFICARE
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PRIVATE HEALTHCARE SYSTEMS
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SAN DIEGO ELECTRICAL H&W TRUST
SEVEN CORNERS, INC
CBCA Administrators, Inc
MEDICARE- J1 MAC - PALMETTO GBA
NIPPON LIFE INSURANCE CO OF AMER
CNA-WC
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BLUE CROSS BLUE SHIELD
ASSURANT HEALTH
MUTUAL OF OMAHA
MOLINA HEALTHCARE OF CALIFORNIA
FREEDOM LIFE INSURANCE CO
EBS-RMSCO INC
ANTHEM BLUE CROSS LIFE AND HEALTH
MEDICARE- J1 MAC - NORIDIAN
PERSONAL INSURANCE ADMINISTRATOR
PAN-AMERICAN LIFE INS COMPANY
SEGUROS MONTEREY-AETNA
UNICARE
AMERICAN HEALTH CHOICE
HEALTH NEW ENGLAND
MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - PALMETTO GBA
USA CARE FFS
MEDICARE- J1 MAC - PALMETTO GBA
MEDICARE- J1 MAC - PALMETTO GBA
HEALTHNET
UNITED HEALTH CARE
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PREFERRED ONE
AETNA GLOBAL BENEFITS
WELLCARE
LIHP
HEALTHSMART BENEFIT SOLUTIONS INC
MVP HEALTH CARE
MEDICARE- J1 MAC - PALMETTO GBA
FIRST HEALTH NETWORK-PCIP
BLUE CROSS OF CALIFORNIA
CAREFIRST ADMINISTRATORS
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TRICARE
GREAT WEST & ANNUITY CO
HUDSON TACTIX
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NIPPON LIFE INS CO. OF AMERICA
MOLINA MEDICARE
CARE1ST HEALTH PLAN MEDICARE
TRANSWESTERN INSURANCE ADMIN, INC.
CARE
SBC COMMUNICATIONS INC.
ADMINISTRATIVE CONCEPTS INC
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AETNA - GEHA
BS OF CA PROMISE HEALTH PLAN M-CAL
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COMMUNITY CARE IPA
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IMPERIAL HEALTH HOLDINGS MEDICAL GROUP
XiMED
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ECLUSIVE (SAN DIEGO PACE)
COMMUNITYCARE
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CONTINENTAL BENEFITS
CENTRIX BENEFITS ADMINISTRATOR INC
<IN1.4.1><IN1.4.1.1>SELMAN </IN1.4.1.1><IN1.4.1.2> COMPANY (SUPP)</IN1.4.1.2></IN1.4.1>
MEDI-SHARE
COAST HEALTHCARE ATTN: CLAIMS DEPT
AETNA MEDICARE SUPPLEMENT
FH CENTER OF SAN DIEGO C/O PEAK HEALTH PLAN
MULTICULTURE COMMERCIAL
PAI-CDPH
PHYSICIANS MUTUAL
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AETNA BETTER HEALTH
HEALTHNET OF CALIFORNIA MDCR RIS
SCRIPPS PHYSICIAN GROUP
BLUE SHIELD MEDICARE ADVANTAGE
BLUE CROSS/BLUE SHIELD ARIZONA
MERITAIN AN AETNA COMPANY
ST PAULS PACE
CONSOLIDATED HEALTH PLANS
CASH PATIENT
XIMED (OLD)
IPMG
UMWA - HEALTH AND RETIREMENT
PRINCIPAL FINANCIAL GROUP
MERITAIN HEALTH. AN AETNA COMPANY
SCAN
ALIGNMENT HEALTH PLAN
integrated Health partners
<IN1.4.1><IN1.4.1.1>EBA</IN1.4.1.1><IN1.4.1.2>M</IN1.4.1.2></IN1.4.1>
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^^
2054-5^Black or African American^HL70005
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BLUE SHIELD OF CA
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MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - NORIDIAN
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MEDICARE- J1 MAC - NORIDIAN
CI COUNTY OF SAN DIEGO
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AETNA LIFE PPO
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TRICARE FOR LIFE
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SHARP COMMUNITY MEDICAL GROUP
UNITED HEALTHCARE-PPO
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CCN-PPO
MEDICARE- J1 MAC - PALMETTO GBA
CIGNA SENIOR-HMO
MEDICARE- J1 MAC - PALMETTO GBA
PACIFIC PHYSICIAN SERVICES
AETNA US HEALTHCARE
CONNECTICARE
GREAT-WEST HEALTHCARE INC.
NATIONAL FINANCIAL INS CO
MEDICARE- J1 MAC - PALMETTO GBA
TEAMSTERS INSURANCE TRUST
BLUE CROSS OF CALIFORNIA
GEICO WEST
SCRANTON REGIONAL OFFICE
TRIBAL HEALTH PARTNERS
BLUE CROSS BLUE SHIELD OF OREGON
CCN
OPERATING ENGINEERS HEALTH
CIGNA PPO
BLUE SHIELD FEP
SHARP ADVANTAGE
MEDICARE- J1 MAC - NORIDIAN
PACIFICARE DO NOT USE
CA IRONWORKERS FIELD WELFARE
MOTION PICTURE INDUSTRY HEALTH P
FIRST HEALTH
AETNA HEALTH PLANS
CCN INC
CCN
B-C B-S OF CONNECTICUT
ANTHEM HEALTH PLAN
WAL-MART PRICING
BLUE SHIELD OF CALIFORNIA
GREAT-do not use bad address
NALC HEALTH BENEFIT PLAN
MEDICARE- J1 MAC - PALMETTO GBA
UNITED HEALTHCARE-PPO
CIGNA HEALTHCARE
SECURE HORIZONS-SHARP REES STEAL
PACIFICARE -PPO
HARRINGTON BENEFITS-CCN
MEDICARE- J1 MAC - PALMETTO GBA
EBA & M CORPORATION
MEDICARE- J1 MAC - PALMETTO GBA
KPC MEDICAL GROUP
BLUE CROSS OF CALIFORNIA
CCN - NGS AMERICAN, INC
THE PLAN HANDLERS
MEDICARE- J1 MAC - NORIDIAN
CARE FIRST HEALTH PLAN- MEDI CAL
BLUE CROSS-BLUE SHIELD FLORIDA
RAILROAD MEDICARE
AETNA
BENESIGHT
BLUE SHIELD OF CA
AETNA LIFE INS CO
LATINO HEALTH CARE
KAISER
BLUE CROSS OF CALIF
BENEFIT COORDINATORS CORP
MULTICULTURAL PRIMARY MED GRP
SCMG- Attn: Dr. Korn
THE WELLNESS PLAN
AETNA US HEALTHCARE-PPO
ADVENTIST HEALTH -CCN
AETNA US HEALTHCARE
MEDICARE- J1 MAC - PALMETTO GBA
BLUE CROSS OF CALIFORNIA
SD ELECTRICAL HEALTH&WELFARE TR.
MEDICARE- J1 MAC - PALMETTO GBA
BLUE CROSS OF CALIFORNIA
PHOENIX GROUP SERVICES
FORMOST, INC
PACIFICARE
UFCW
RAILROAD MEDICARE
UNITED HEALTH-MET LIFE
MEDICARE- J1 MAC - PALMETTO GBA
HELLER ASSOCIATES
UNITED HEALTHCARE - POS
UNITED HEALTHCARE
UNITED HEALTHCARE
MEDICARE- J1 MAC - PALMETTO GBA
UNICARE
SHARP CHULA VISTA MED CNTR
ADVENTIST HEALTH-CLAIMS CENTRAL
SHARP ADVANTAGE-SHARP HLTH PLAN
AETNA US HEALTHCARE
CCN-PLAN HANDLERS- DO NOT USE
CCN ELECT
AETNA US HEALTHCARE
FIRST HEALTH NETWORK
PRUDENTIAL HEALTHCARE
PACIFICARE-HMO
BLUE CROSS-BLUE SHIELD NEW JERSE
CIGNA HEALTHCARE
CCN INSURANCE- DO NOT USE
GUARDIAN INS
AETNA US HEALTHCARE-DIRECT
CIGNA HEALTHCARE-PPO
MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - PALMETTO GBA
BLUE CROSS
SCRIPPS EPO
SECURE HORIZONS
MEDICARE- J1 MAC - NORIDIAN
SAN DIEGO HOSPICE
UNITED AMERICAN-COMM
ASSOC. 3RD PARTY ADMINISTRATORS
MEDICARE- J1 MAC - NORIDIAN
SCMG- Attn: Dr. Korn
CORE SOURCE
AFFILIATED HEALTH
UNICARE
UNIVERSAL CARE
AETNA US HEALTHCARE- DO NOT USE
UNITED HEALTHCARE
CONSECO
UNITED HEALTHCARE
PRINCIPLE LIFE INSURANCE CO
UNICARE
PV ER UNFUNDED-INDIGENT PROGRAM
PACIFICARE-POS
RETA PLAN
TRICARE PRIME
AMALGAMATED LIFE INSURANCE CO
BLUE CROSS OF CALIFORNIA
MEDICARE- J1 MAC - PALMETTO GBA
STRATEGIC RESOURCE CO.
ONE HEALTH
BLUE CROSS OF CA
CIGNA -HMO
MAYO MGMT SERVICES, INC
AETNA US HEALTHCARE
SCHALLER ANDERSON
SCRIPPS MERCY MEDICAL GROUP
SHARP MISSION PARK MED GRP
MAXICARE LIFE & HEALTH CO.
SCRIPPS CLINIC HEALTH PLAN
USI ADMINIDTORATORS OF NEVADA
SIHO INSURANCE
HEALTH PLANS, INC.-CCN
SCRIPPS PHYSICIAN MED CORP-FFS
PAN-AMERICAN LIFE INS COMPANY
CIGNA HEALTHCARE
CIGNA -PPO
MEDICARE- J1 MAC - PALMETTO GBA
CORPORATE HEALTH STRATEGIES
MEDI-CAL
MEDICAL MGT SERCIES CTR -WC
SCRIPPS COASTAL MEDICAL (SCMC)
MEDICARE- J1 MAC - PALMETTO GBA
BLUE SHIELD-BLUE CARD PROGRAM
EA-PARADISE VALLEY
SCRIPPS PHYSICIAN
NATIONWIDE
MEDICARE- J1 MAC - PALMETTO GBA
SYCUAN MEDICAL HEALTH PLAN
CIGNA HLTHCARE - PPO
WAUSAU INSURANCE CO
MEDICARE- J1 MAC - PALMETTO GBA
CARPENTERS HLTH & WELFARE - CCN
MEDICARE- J1 MAC - PALMETTO GBA
AETNA US HEALTHCARE
MEDICARE- J1 MAC - PALMETTO GBA
BRIDGESTONE-FIRESTONE
BLUE CROSS OF CA - PPO
MEDICARE- J1 MAC - NORIDIAN
BLUE CROSS BLUE SHIELD
PLAN HANDLERS, INC.
MEDICARE- J1 MAC - NORIDIAN
AETNA US HEALTHCARE -PPO
AMERICAN FIDELITY ASSURANCE COMP
STATE FARM INSURANCE COMP
KEMPER INSURANCE CO.
MEDICARE- J1 MAC - PALMETTO GBA
BLUE CROSS OF CALIFORNIA
PEOPLE BENEFIT LIFE
FCE BENEFITS ADMINISTRATOR
SOUTHERN CALIFORNIA DRUG BENEFIT
CALIFORNIA IRONWORKERS FIELD
CCN
LUCY POLAK, MD
AETNA US HLTHCARE
SHARP REES STEALY-GROSSMONT
GE FINANCIAL ASSURANCE
MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - PALMETTO GBA
MEGA LIFE & HEALTH INS COMP.
SHARP CHULA VISTA EA
AETNA US HEALTHCARE
HEALTH NET
MEDICARE- J1 MAC - PALMETTO GBA
EMPLOYEE BENEFIT MNGMT SERVICE
GEGLAC MEDICAL CLAIMS
MEDICARE- J1 MAC - NORIDIAN
RELIGIOUS COMP TRUST - CHRISTIAN BROTHERS SER
BLUE CROSS-BLUE SHIELD PPO
GEHA-PPO
MEDICARE- J1 MAC - PALMETTO GBA
AMERIHEALTH ADMIN.
AETNA US HEALTHCARE
PHCS- JF MOLLOY AND ASSOC.
BRISTLE PARK MED GROUP
TRAVELERS INSURANCE
COVENTRY HEALTH CARE
AMERIBEN SOLUTIONS
MEDICARE- J1 MAC - PALMETTO GBA
SWA SOUTHWEST ADMINISTRATORS INC
MNUI
SHEET METALS WORKER LOCAL 206
CCN- PARADISE VALLEY HOSPITAL
PUBLIC ADMINISTRATOR*GUARDIAN
MEDICARE- J1 MAC - NORIDIAN
CHP HEALTH BENEFITS TRUST
ANDREW PARASHOS
NHR TAMPA FLORIDA
MEDICARE- J1 MAC - PALMETTO GBA
BLUE SHIELD OF CALIFORNIA
CCN-HELLER ASSOCIATES
PHCS-CORP BENEFITS
Wells Fargo- Leave Processing
ALLIED ADMINISTRATORS
MEDICARE- J1 MAC - PALMETTO GBA
TRIWEST
AETNA HEALTH PLANS
BC-PRUDENT BUYER
CMS(CI)
MORGAN WHITE INSURANCE
AETNA US HEALTHCARE
MCAL-LA COMMUNITY HEALTH PLAN
SHARP CHULA VISTA EA
AMADEX
GOLDEN EAGLE
DO NOT USE
CARPENTERS HEALTH & WELFARE FUND
SHARP COMMERCIAL-INDEPENDENT
MEDICARE- J1 MAC - PALMETTO GBA
CCN-MOUNTAIN STATES ADM SVCS
EQUITABLE INS
BLUE CROSS PPO
UNITEDHEALTHCARE
BLUE CROSS- MEDICAL HMO
NAT ASSN OF LET CAR
UNITED FOOD & COMM
PGBA
CENTRAL VALLEY TRUST-BLUE CROSS
TRIWEST
CCN
BLUE CROSS OF CALIFORNIA
CHAMPVA
MEDICARE- J1 MAC - PALMETTO GBA
CIGNA HEALTHCARE
SEAFARERS WELFARE
HEALTH NET PPO
UNITED HEALTH-PPO
SECURE HORIZONS
ADVANCED BENEFIT SOLUTIONS LLC
AARP-UNITED HEALTHCARE CLAIM
CIGNA HEALTHCARE-PPO
UNICARE
PRUDENTIAL INSURANCE COMPANY
OPERATING ENG-PENSIONED-PRU
UNICARE
MEDICARE- J1 MAC - NORIDIAN
CIGNA HEALTHCARE
GREAT WEST & ANNUITY CO
PRECISE GROUP
MEDICARE- J1 MAC - NORIDIAN
BENESIGHT
SPECIALTY RISK MANAGMENT
THE CAPELLA GROUP
AETNA LIFE
UNITEDHEALTHCARE
CIGNA-HMO
FIRST HEALTH
ONE HEALTH PLAN -HM
PERS CARE
SOUTHWEST ADMINISTRATORS
MEDICARE- J1 MAC - PALMETTO GBA
CCN
Mega Life Ins Company
FREMONT COMP
DELTA HEALTH SYSTEMS
GNP GRUPO NACIONAL P
ZENITH INSURANCE
PLAN HANDLERS GROUP 845
FIRST HEALTH
GRUOP & PENSION ADMINISTRATORS
MEDICARE- J1 MAC - NORIDIAN
LIBERTY MUTAL FIRE INSURANCE
TRUSTMARK INSURANCE COMPANY
WAUSAN BENEFITS
MUTUAL OF OMAHA
ASSOCIATION SOCIETY INS. CORP.
BLUE CROSS
OXFORD HEALTH PLANS
SYNA MED
AETNA-HMO
SINCLAIR HEALTH SERVICES
MAIL HANDLERS BENIF PLAN
MEDICARE- J1 MAC - PALMETTO GBA
CCN
HEALTHLINK
SCRIPPS EA EMERGENCY AND ACUTE
FISERV HEALTH
CALFARM LIFE INSURANCE
MERCY PHYSICIANS MED GRP
CORE SOURSE
CARPENTERS HEALTH & WELFARE FUND
THE EPOCH GROUP L.C
MEDICARE- J1 MAC - PALMETTO GBA
STAY WELL INSURANCE
GREAT WEST HEALTHCARE
UNICARE
AETNA HMO
MEDICAID-OUT OF STATE
THE GOODYEAR TIRE & RUBBER COMPA
HIGHMARK BLUE CROSS
BLUE CROSS- PPO
UNITED HEALTHCARE
OLYMPUS MANAGED HEALTH CARE INC
ALLIED ADMINISTRATORS
UNICARE
BENEFIT ADMINISTRATIVE SYSTEMS L
PACIFIC LIFE AND ANNUITY
MEDICARE- J1 MAC - PALMETTO GBA
BLUE CROSS OF CA.
BANKERS FIDELITY
UNITED HEALTHCARE CHOICE
COMMUNITY ADMINISTRATORS
AMALGAMATED LIFE INSURANCE
CHESTERFIELD RESOURCES INC.
CHAMPVA CENTER
INTERPLAN HEALTH GROUP
HEALTH NET PPO
MAIL HANDLERS BENIF PLAN
ALLNATION INSURANCE COMPANY
CORESOURCE
CCN
FCE
FIRST HEALTH
OFFICE OF GROUP BENEFITS
MEDICARE- J1 MAC - NORIDIAN
SELF-PAY
BLUE CROSS PPO
FOOD EMPLOYERS & BAKERY
MEDICARE- J1 MAC - NORIDIAN
UNION FIDELITY LIFE INS COMPANY
MEDICARE- J1 MAC - PALMETTO GBA
BEECH STREET CORPORATION
ALLIANZ
MEDICARE- J1 MAC - PALMETTO GBA
CARE FIRST HEALTH PLAN- MEDI CAL
CONSECO SENIOR HELTH PLAN
PINNACLE CLAIMS MANAGEMENTIC
MULTICULTURAL - MEDI-CAL
LA VIDA MEDICAL GROUP & IPA
HAWAII PACIFIC MEDICAL REFERRALS
MEDICARE- J1 MAC - PALMETTO GBA
MITSUI SUMITOMO
BLUE CROSS HMO
CCN
KAISER-COMM
AZ BENEFIT OPTIONS-HARRINGTON
WPAS
SHASTA ADMINISTRATIVE SERVICES
AETNA-SRC
AFFLIATED
UNITED HEALTHCARE
BLUE CROSS-MCAL
THRIVENT FINANCIAL
BANKERS LIFE AND CASUALTY
UNITED HEALTHCARE
PACIFICARE
KLAIS & COMPANY, INC.
CAMBRIDGE
SOUTHWEST CARPENTERS HEALTH
UNION PACIFIC RAILROAD EMPLOYEES
SEDWICK CMS
WASHINGTON NATIONAL
CAREPLUS
Sedwick Insurance
PRIVATE HEALTH CARE SYSTEM
AETNA STUDENT HEALTH
BLUE CROSS- BLUESHIELD OF ILLINO
AETNA LIFE INSURANCE
MEDICARE- J1 MAC - PALMETTO GBA
BLUE CROSS OF CALIFORNIA
SAN DIEGO TRANSIT
GALLAGHER BASSETT
WASHINGTON NATIONAL
UNITED HEALTHCARE-PPO
UNITEDHEALTHCARE
MEDICARE- J1 MAC - PALMETTO GBA
SHARP REES STEALY MEDICAL GROUP
CAPITAL BLUE CROSS.
FEDERATE HR SERVICES
CAMBRIDGE INS COMPAY WC CLAIMS
TRIBAL HEALTH PLAN
TRISTAR RISK MGMT
BRIDGESTONE - FIRESTONE
LAUNDRY &DRY CLEANING WORKERS
MERITAIN HEALTH
FIRST HEALTH NETWORK
KAISER PERMANENTE
JOHN ALDEN LIFE INSURANCE COMPAN
SCAN HEALTH SMMG
KAISER HMO
SCAN HEALTH
LABOR HEALTH AND WELFARE TRUST
CIGNA HEALTHCARE
AMERICAN REPULIC INC
MEDICAL MUTUAL
INSURANCE CENTER
MEDICAL-OUT OF STATE
MEDICAL
SEDGWICK C M S ORANGE
HTH WORLDWIDE INS. SERV.-ADMIN
SAN DIEGO COUNTY SCHOOLS
ALLIED ADMINSTRATORS
HEALTH NET
BLUE SHIELD
BLUE SHIELD
INSURANCE CENTER
BLUE CROSS PPO
WELLCARE PRIVATE FEE FOR SERVICE
FIRST HEALTH NETWORK
MEDICARE- J1 MAC - NORIDIAN
BERSHINE HATHAWAY HOMESTEAD
UNICARE
MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - NORIDIAN
KAISER
MEGAHEALTH & LIFE INSURANCE
MEDICARE- J1 MAC - PALMETTO GBA
ANTHEM BLUE
HEALTHNET
FIRST HEALTH INS. CENTER
OPERATING ENGINEERS
CALOPTIMA EDS CROSSOVER UNIT
UMR
MEDICARE- J1 MAC - PALMETTO GBA
AMERICAN MEDICAL SECURITY
UNITED HEALTHCARE
CMS
IMMIGRATION HEALTH SERVICES
PHCS
WESTERN & SOUTHERN BENEFITS DEPA
KAISER SR HMO
CINERGY HEALTH
DGA PRODUCER HEALTH PLANS
ILWU
HEALTH NET HMO
I.D.A.
PACIFICARE
MEDICARE- J1 MAC - PALMETTO GBA
PRIVATE HEALTHCARE SYSTEMS
MOUNTAIN STATES ADMINISTRATIVE
SAN DIEGO ELECTRICAL H&W TRUST
SEVEN CORNERS, INC
CBCA Administrators, Inc
MEDICARE- J1 MAC - PALMETTO GBA
NIPPON LIFE INSURANCE CO OF AMER
CNA-WC
BEST DOCTORS
BLUE CROSS BLUE SHIELD
ASSURANT HEALTH
MUTUAL OF OMAHA
MOLINA HEALTHCARE OF CALIFORNIA
FREEDOM LIFE INSURANCE CO
EBS-RMSCO INC
ANTHEM BLUE CROSS LIFE AND HEALTH
MEDICARE- J1 MAC - NORIDIAN
PERSONAL INSURANCE ADMINISTRATOR
PAN-AMERICAN LIFE INS COMPANY
SEGUROS MONTEREY-AETNA
UNICARE
AMERICAN HEALTH CHOICE
HEALTH NEW ENGLAND
MEDICARE- J1 MAC - NORIDIAN
MEDICARE- J1 MAC - PALMETTO GBA
USA CARE FFS
MEDICARE- J1 MAC - PALMETTO GBA
MEDICARE- J1 MAC - PALMETTO GBA
HEALTHNET
UNITED HEALTH CARE
SCRIPPS COASTAL MEDICAL GROUP
PREFERRED ONE
AETNA GLOBAL BENEFITS
WELLCARE
LIHP
HEALTHSMART BENEFIT SOLUTIONS INC
MVP HEALTH CARE
MEDICARE- J1 MAC - PALMETTO GBA
FIRST HEALTH NETWORK-PCIP
BLUE CROSS OF CALIFORNIA
CAREFIRST ADMINISTRATORS
HEALTHNET MEDICARE RISK
TRICARE
GREAT WEST & ANNUITY CO
HUDSON TACTIX
UHC- COMMUNITY PLAN
FIRST HEALTH
EMERGENCY ASSISTANCE JAPAN (EAJ)-SOMPO
PRIVATE HEALTHCARE SYSTEMS
INTEGRA BMS
STERLING INSURANCE OPERATIONS
MEDICARE- J1 MAC - NORIDIAN
NIPPON LIFE INS CO. OF AMERICA
MOLINA MEDICARE
CARE1ST HEALTH PLAN MEDICARE
TRANSWESTERN INSURANCE ADMIN, INC.
CARE
SBC COMMUNICATIONS INC.
ADMINISTRATIVE CONCEPTS INC
MOLINA DUAL OPTIONS
AETNA - GEHA
BS OF CA PROMISE HEALTH PLAN M-CAL
BRAND NEW DAY ATTN CLAIMS DEPT
COMMUNITY CARE IPA
BS OF CA PROMISE HEALTH PLAN MDCR
MOLINA MARKETPLACE COVERED CA
PRIMARY CARE ASSOCIATES OF CALIFORNIA
IMPERIAL HEALTH HOLDINGS MEDICAL GROUP
XiMED
GOLDEN PHYSICIANS MEDICAL GROUP
ECLUSIVE (SAN DIEGO PACE)
COMMUNITYCARE
ALLIED NATIONAL C/O GLOBAL CARE
TRICARE WEST
CONTINENTAL BENEFITS
CENTRIX BENEFITS ADMINISTRATOR INC
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MEDI-SHARE
COAST HEALTHCARE ATTN: CLAIMS DEPT
AETNA MEDICARE SUPPLEMENT
FH CENTER OF SAN DIEGO C/O PEAK HEALTH PLAN
MULTICULTURE COMMERCIAL
PAI-CDPH
PHYSICIANS MUTUAL
PROSPECT MEDICAL SYSTEM
MOLINA MCAL
PEAK HEALTH PLAN
MAGNA ADMINISTRATORS
SCRIPPS HEALTH PLAN
DIRECT CARE ADMINISTRATORS
SOUTHERN CA PHYSICIAN MED SERV.
AETNA BETTER HEALTH
HEALTHNET OF CALIFORNIA MDCR RIS
SCRIPPS PHYSICIAN GROUP
BLUE SHIELD MEDICARE ADVANTAGE
BLUE CROSS/BLUE SHIELD ARIZONA
MERITAIN AN AETNA COMPANY
ST PAULS PACE
CONSOLIDATED HEALTH PLANS
CASH PATIENT
XIMED (OLD)
IPMG
UMWA - HEALTH AND RETIREMENT
PRINCIPAL FINANCIAL GROUP
MERITAIN HEALTH. AN AETNA COMPANY
SCAN
ALIGNMENT HEALTH PLAN
integrated Health partners
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UNITED WORLD LIFE INSURANCE
Address2
Insurance Plan/Name
City
Insurance ID#
State
------Select-------
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Group ID#
Zip Code
Insured Name
Home Phone
Insured DOB (mm-dd-yyyy)
Cell Phone
Insured Relationship
Self
Spouse
Father
Mother
Other
Work Phone
Address
Email ID
City
Employer
State
------Select-------
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Emergency Contact
Zip Code
Emergency Phone
Medications
1-See attached/scanned list , reviewed by MD and MA
2-Unknown to patient, no list provided
3- No new medications
4-Patient unsure of medications, will review records
6 MP
Aceon
Acetaminophen
Aciphex
Actace
Actonel
Actoplus Met
Actos
Adalat CC
adavon
Adderall
Advair
Advicor
Advil
Advil Migraine
Afeditab CR
Agenerase
Aggrenox
Aggrenox
Agrylin
Albuteral
Aldactone
Alinia
Alka Mints
Alkets
Alkums
Allegra
Aloxi
Alprazolam
Altace
Altoprev
Amaryl
Amatiza
Ambien
Ambien
Amerge
Amilac
Amiloride/HCTZ
Amitiza
Amitone
amlodipine
Amoxil
Ampicillin
Ampicillin injection
Anacin-3 Maximum Strength
Analpram-HC
Ancef
Angiomax
Antara
Antispas
Antispasmodic
Antivert
Anusol HC sup
Anusol-HC Cream
Anzemet
Apidra
Apresoline
Apriso
Aptivus
Aralen
Aricept
Arixtra
Armour Thyroid
Asacol
Asaphex
ASFAGg
ASFAGGGGGS
Aspirin
Atacand
Atacand HCT
Atenolol
Atripla
Augmentin
Augmentin ES-600
Augmentin XR
Avalide
Avandamet
Avandaryl
Avandia
Avapro
Avelox
Avinza
Avodart
Axert
Axid
Axocet
Azulfidine
Azulfidine EN
B-12
B.O. RX FOR IBS- Rifaximin or flagyl if not covered with probioitcs
Bacitracin Ointment
Baclofen
Bactrim
Bactrim DS
Baraclude
Barbidonna
Bayer Aspirin
Bayer Aspirin Childrens
Bayer Aspirin Regimen
Bayer Aspirin Regimen with Calcium
Bayer Extra Strength
Benecar
Benicar
Benicar HCT
Bentyl
Biaxin
Biaxin XL
Bidil
Birth control pills
Boniva
Budesonide inhaler
Bumetanide
Bumex
butalbital
Byetta
Bystolic
Caduet
Cal Oys
Cal-Gest
Calan
Calan SR
Calcarb
Calci Mix
Calci-Chew
Calcitab
Calcium
Calcium /D
Caltrate
Caltro
CANASA Suppositories bid
Capoten
Captopril
Carafate
Carbamazephine
Carbetalol
Cardene
Cardene SR
Cardizem
Cardizem CD
Cardizem LA
Cardura
Cariopa-levodopa
Cartia XT
carvedicol
Catapres
Catapres-TTS
Ceclor CD
Cedax
Cefaclor
Cefaclor ER
Ceftin
Cefzil
celebrex
Celexa
Centrum
Chantix
Childrens Mylanta
Chlordinium
Chooz
Cimzia
Cipro
Cipro Oral
Cipro XR
Ciprofloxacin
Citrucel
Citrucel SF
Cleocin
Clindex
clindinium
Clonazepam
Clorpres
Colace
Colace
Colazaal
Colchicine
Colchicine/Probenecid
Colestid
Colyte
Colyte w/ Flavor Packs
Colyte-Flavored
Combipres
Combivir
Combunox
Compazine
Constilac
Constipation meds-Docusate 500mg q HS and miralax 17gr. qod and adjust.Progressive constant multiple modality therapy(M)
Constulose
Continue current Meds
Continue same medication
Copegus
CoQ10
Cordarone
Coreg CR
Corgard
Corzide
Coumadin
Coumadin
Covera-HS
Cozaar
Creon
Creon
Crestor
Crixivan
cuarfarin-sodium
Cubicin
Cymbalta
Cytomel
Cytotec
Cytovene
Darvocet-N
Darvon
Decadron
Demadex
Demerol Oral
Depakote
Depo-Medrol
Detrol
Dexamethasone
Dexilant
Diabeta
Dicarbosil
Diclofenac
Diflucan
Digitek
Digoxin
Dilacor XR
Dilantin
Dilatrate-SR
Dilaudid
Dilaudid-HP
Diltia XT
Diltiazem
Diovan
Diovan HCT
Dispermox
Ditiazem
Diuril
Docusate
Dolophine
DOMPERIDONE 10 MG BID AC
Donnapine
Donnatal
Donnatal Extentab
Donnatal Extentabs
Duetact
Dulcolax q 3d as rescue
Duragesic
Duricef
Dyazide
Dynacin
Dynacirc
Dynacirc CR
Dyrenium
E.E.S.
Ecotrin
EES
Elixiral
Emend
Emtriva
Enablex
Enalapril
Enbrel
endocet
Enulose
Enzone
Epivir
Epivir-HBV
Epzicom
Equilet
Eraxis
Ery-Tab
Eryc
Erythrocin
Esidrix
Estrodiol
Evista
Excedrin
Excedrin Back & Body
Excedrin Migraine
Exforge
Exubera
Factive
Famvir
Fasomax
Feldane
Fendyl
Fentanyl Patch
Fibercon
Fioricet
Fioricet with Codeine
Fiorinal with Codeine
Flagyl
Flagyl
Fleet Bisacodyl
Flomax
Flonase
floricet
Flovent
Floxin
Flumadine
Folic Acid
Fortamet
fosamax
Fosinopril/Hydrochlorothiazide
Fragmin
Frova
Furosemide
Fuzeon
Gaviscon 30 cc pc
Genuine Bayer Aspirin
glimepiride
Glipizide
Glipizide ER
Glucophage
Glucophage XR
Glucosamine Chondroitin
Glucotrol
Glucotrol XL
Glucovance
Glumetza
Glyburide
Glycerin suppositories prn.
Glycolax
Golytely
Grifulvin V
Haldol
HalfLytely and Bisacodyl
HCTZ
HELICOBACTER therapy-Amoxi 500 ii bid, clarithromycin 500 bid and omeprazole 20 bid x 14 d.
Helidac
Heparin
Hepsera
Hivid
HP Rx- Amoxicillin 500 ii po bid, clarithromycin 500mgs po bid and omeprazole 20 mg po bid PEPTO QID for 14 days WITH BREATH HP IN 2 MONTHS OFF PPIs(M)
Humalog
Humalog Mix 75/25
Humara
Humira
Humulin 50/50
Humulin 70/30
Humulin N
Humulin R
Hydralazine
Hydrochlorothiazide
hydrocodone
Hydrocortisone Suppository 25 mg PR QHS
hydrocortisone suppository 25mg
HydroDIURIL
Hyosophen
Hytrin
Hyzaar
IgG IV fusion
Imdur
Imitrex
Imodium A-D
Indapamide
Inderal
Inderal LA
InnoPran XL
Inspra
Insulin
Integrilin
Intron A
Iron sulfate
ISMO
Isoniazid
Isoptin SR
Isordil
Isordil Titradose
Isosorbide Dinitrate
Janumet
Januvia
Kadian
Kaletra
Keflex
Ketek
Klonopin
Konsyl
Kristalose
Kytril
Lactulose
Lamisil
Lanoxicaps
Lanoxin
lansoprazole
Lantus
Lariam
Lasix
Lescol
Lescol XL
Letairis
Levaquin
Levbid
Levemir
Levomere
Levoxyl
Levsin
Lexapro
Lexxel
Lialda
Librax
LIDOCAINE PATCH BID
LINZESS
Lipitor
Lisinopril
Lithium
Lofibra
Lomotil
Lopid
Lopressor
Lopressor HCT
Lorcet
Lorcet 10/650
Lorcet HD
Lorcet Plus
Loricel
Lortab
Losartan
Lotensin
Lotensin HCT
Lotrel
Lotronex
Lovaza
Lovenox
Lovestatin
Lozol
Lunesta
lyrica
Macrobid
Macrodantin
Malarone
Marinol
Mavik
Maxalt
Maxalt MLT
Maxaquin
Maxzide-25
Meclizine
Medrol
Megace
Meloxicam
Mepron
Mercaptopurine
Metaglip
Metamucil
Metaprolol
Metformin
Methadose
Mevacor
Mexiletine
Micardis
Micardis HCT
Micronase
Minipress
Minitran
Miralax
Moduretic 5-50
Monodox
Monopril
Monurol
Morphine
Motrin
Motrin
Motrin Migraine
Moviprep
MS Contin
Mucinex
Multaq
Multi Vit
Multivitamin
Myambutol
Mycostatin
Mykrox
Mylanta Gas Maximum Strength
Mylanta Gas Maximum Strength Softgels
Mylanta Gas Regular Strength
Mylanta Gelcaps Antacid
Mylanta Maximum Strength Liquid
Mylanta Regular Strength Liquid
Mylanta Supreme
Mylanta Ultra Tabs
Naprosyn
Nasonex
Nephro Calci
Nexium
Niaspan
Nifedical XL
Nifedipine
Nitrek
Nitro-Bid
Nitro-Dur
nitroglycerine
Nitrolingual Spray
NitroMist
Nitrostat
Nizoral
No Medication
No Medications
No Medications
None
Noroxin
Norpace
Norpace CR
Norvasc
Norvir
Novolin 70/30
Novolin N
Novolin R
Novolog
Novolog Mix 70/30
NTG 0.125%
Nubain
Nucynta
Nulev
Nulytely
nuvigil
Nydrazid
Nystatin
Omeprazole
Omnicef
Omnipen
ondansetron
Opana
Opana ER
Orapred
OsCal 500
Osmoprep
Oxycodone
Oxycontin
Oysco 500
Oyster Cal 500
Oyster Shell Calcium 500
Pantoprazole
Pantoprazole
Patient does not know nor brought list
Patient takes No Medications
Patonic
Paxil
PCE
PEG-Intron
Pegasys
Penicillin VK
Pentasa
Pentazine
Pepcid
Pepcid AC
Pepcid Complete
Pepcid RPD
percocet
Persantine
Phazyme
Phenadoz
Phenergan
Phenergan (rectal)
Pindolol
Plaquenil
Plavix
Plendil
Pletal
pomergrom
Potassium
PPI COVERED BY INSURANCE THAT IS NOT OMEPRAZOLE (ineffective) : ACIPHEX 20, NEXIUM 40, DEXILANT 60, PROTONIX 40 OR ZEGERYD 40-ONE TAB p.o. BID #60/REFILL 6
Prandin
Pravachol
pravastatin
Prazosin
Precose
Prednisone
Premarin
Prempro
Prenatal Vitamins
Prevacid
Prevacid IV
Prevacid Naprapac
Prevacid Solutab
Prevpac
Prezista
Prilosec
Prilosec OTC
Prinivil
Prinzide
Pristiq
Probenecid
Probiotics
Procanbid
Procardia
Procardia XL
Prochlorperazine
Proctocort Cream
Proctocream HC
Proctofoam-HC
Proctosol HC
Proctozone-HC
Promacot
Promethegan
Propylthiouracil
Proquin XR
Protonix
Protonix
Pulmicort
Pylera
Pyrazinamide
Questran
Quinapril
Quinidine sulfate
Ramipril
Ranexa
Rebetol
Rebetron
Rebif
Refludan
REGLAN- 10 MG PO Q AM , THEN BID IF TOLERATED. BLACK BOX WARNING EPS EXPLAINED AND UNDERSTOOD. INSTRUCTIONS TO STOP MEDS PRN UNDERSTOOD. RISK OF PERMANENT EPS UNDERSTOOD.
Relenza
Relpax
Remeron
Remicade
Remodulin
Repear colonoscopy 2 year
Rescriptor
Retrovir
Revatio
Reyataz
RhoGAM
Rhythmol
Rhythmol SR
Rifater
Riomet
Rocephin
Rolaids Sodium Free
Rowasa
Saw Palmetto
Sectral
See Med List in Chart
Senokot
Septra
Septra DS
Seroquel
Sertraline
simcore
Simvastatin
Singulair
Skelaxin
Solodyn
Spasmolin
Spectracef
Spiriva
Spironolactone
Starlix
Sular
Sulcralfate
Sulfatrim Pediatric
Sumycin
Suprax
Sustacal,Boost or equivalent
Sustiva
Symlin
Symmetrel
Synercid
Synthroid
Tagamet
Tambocor
Tamiflu
Tapazole
Tarka
Taztia XT
Tekturna
Tenex
Tenormin
Terazosin
Teveten
Thorazine
Thyrolar
Tiazac
Ticlid
Tigan
Timolol
Tindamax
Tirosint
Tizanadin
Tobi
Toprol-XL
Tramadol
Transderm Scop
Trental
Triamterine hctz
Tricor
Trizivir
Truvada
Tucks , balneol lotion on wet paper or baby wipes.
Tums
Tums Ultra
Tygacil
Tylenol
Tylenol
Tyzeka
Uniretic
Unithroid
Univasc
UNKNOWN to patient
Valcyte
Valtrex
Vancocin
Vantin
Vaseretic
Vasotec
Veetids
Ventavis
Verapamil
Verelan PM
Vfend
Vibra-Tabs
Vibramycin
Vioxx
Viracept
Viramune
Viread
Visicol
Visken
Vit E 400 IU bid
Vitamin B-12
Vitamin C
Vitamin D
Vytorin
Warfarin
WEAN OFF PPI-qod then prn
Welchol
Wellbutrin
xalatan
Xanax
Xifaxan
Zantac
Zantac OTC
Zaroxolyn
Zebeta
Zegerid
Zerit
Zestoretic
Zestril
Zetia
Ziac
Ziagen
Zithromax
Zmax
Zocor
Zofran
Zofran Injection
Zoloft
zolpidem-tartrate
Zomig
Zosyn
Zovirax
Ztihromax
Zyrtec
Dosage
Direction
Allergies
Reaction
Allegra
Allopurinol
Amoxicillin
Antihypertensives
Aspirin
Augmentin
Benecar
Blood products
Ceclor
Cephalosporins (and all related antibiotics)
Certain post-surgery fluids
Cigarette and Cigar Smoke
Cipro
Codeine
Cortisone
Cozaar
Dairy
Dust
Dyazide
Eggs
Erythromycin
Fish
General Anesthesia
Glucophage
Gluten
Glyburide
Hydrocodone
Insulin
Iodine
IV Contrast Dye
Lantus
Latex
Levaquin
Local Anesthetics (novocaine, lidocaine)
Mold
Muscle relaxants
Non Steroidal AntiInflammatory Drugs (NSAID), including aspirin, ibuprofen and naproxen
Peanuts
Penicillin
Pet dander
Pollen
Radiocontrast media
Ragweed
Shellfish
Soy
Sulfa
Sulfa
Sulfa antibiotics
Sulfites
Sulfonamides (including antibiotics, oral diabetes medications and some water pill diuretics)
Tegretol
Tree Nuts
Vaccines
Wheat
Zithromax
difficulty breathing, wheezing, chest tightness
loss of consciousness
hives, welts, or wheals
generalized erythema (redness)
swelling in the face, eyelids, lips, tongue, throat, hands, and feet
coughing, hoarseness
nasal congestion, sneezing
rapid or irregular heart beat
dizziness, faintness
tingling or sensation of warmth
difficulty swallowing
nausea, vomiting
diarrhea, abdominal cramping, bloating
anxiety, fear, feeling that you are going to die
confusion
Medical History
Abnormal LFTs, liverfunction tests
COPD, chronic obstructive pulmonary disease
H.pylorii history, s/p Rx
Obesity
Allergies
Crohn's Disease
Headache
OBESITY
Alzheimer’s disease
CVA
Heart disease
OBESITYelevated BMI
Anemia
CVA HX
Hemorrhoids, s/p ablation
Osteoporosis
Anxiety
Depression
Hepatitis C
Pagets Disease
ANXIETY
DEPRESSION/OTHER
High blood pressure
Pancreatitis
Arthritis
Diabetes
High cholesterol
PARKINSONS
ASCVD,atheroslcerotic cardiovascular disease
Diabetes Type I
History of blood transfusions
PAST CHART Scanned, Reviewed and discussed with patient
Asthma
Diabetes Type II
HTN
Psoraiasis
ASTHMA
Diverticulitis
HTNHypertension
PUD, peptic ulcer disease
Atrial Fibrilation
DJD
HYPER LIPIDEMIA
Rectal Bleeding
Back pain
DJD (Degenerative joint disease)
Hypercholesterolemia
Renal Insufficency
Barrett's Esophagus
DM
Hyperlipidemia
Rheumatoid Arthritis
Bone, joint, or muscular problems
DM II Diabetes mellitus
Hypertension
SCANNED into EMR, no significant change in PMHx, SHx, ROS, FHx. Discussed and reviewed with patient.
BPH
Emphysema
hypertriglyceridemia
SCHIZ
Breast Cancer
Epilepsy
HYPOTHYROID
Schizophrenia
CAD
ESRD
Hypothyroidism
SCREENING Colon Cancer
CAD, coronary artery disease
ESRD
Irritable Bowel Syndrome
Sleep apnea
CancerColon
Fatty liver history
Lactose intolerance, unspecified
SMOKER
CHF
Fibromyalgia
Liver disease
STENT HX
Chronic pain
GALLSTONES
Lymphoma
Systemic Lupus erythematosus
CKD
gastritis
Manic Depression Disorder
Tachycardia
Colitis
Gastroesphageal Reflux Disease
METABOLIC SYNDROME
test
Collagenous Colitis
GAVE Watermelon Stomach
MI history
Ulcerative Colitis
Colon polyp
GERD without esophagitis
Migraine
Unremarkable
Constipation
GERDGastroesophageal reflux disease
Nose bleeding
Vision problems
COPD
Graves disease
Other
Surgical History
AICD
Anal fissure
Angioplasty
Appendectomy
Appendicitis
Balloon angioplasty of coronary artery
Breast biopsy
Breast lumpectomy
Burns (3 degree) s/p skin transplant
C Section
CABG
Cardiac ablation
Cardiac catheterization
Cataract surgery
Cesarean section
Cholecystectomy
colon cancer
Colon Resection
Colonoscopy
Coronary artery bypass
Coronary Stents
D&C
EGD
ER Visit
GI Bleed
Heart Transplant
Hemorrhoidectomy
Hemorrhoids
Hepatitis
Hernia repair
Hiatal Hernia Repair
Hysterectomy
Hysterectomy - partial
Kidney stone
Knee
Knee replacement
Lower-back surgery
Mastectomy
No previous surgery
OOpherectomy
Pacemaker
PPM
PUD
Ros Sheet Reviewed by MD
Roux en Y gastric bypass for obesity
shoulder
Surgery
Tand A
Tonsillectomy
Total hip replacement
Unknown reasons-patient not sure
Operation
Procedure
Surgery
Date (mm-dd-yyyy)
Family History
Patient was adopted
If deceased, cause of death
Brother
Child
Father
Grandparents
Maternal Aunt
Maternal Father
Maternal Mother
Maternal uncle
Mother
Paternal Aunt
Paternal Father
Paternal Mother
SEE OLD CHART, NO CHANGE
Sister
Abdominal pain
Anemia
Arthritis
Asthma
Bladder cancer
Breast cancer
CAD
Celiac disease
Colon cancer
Colon polyp
Constipation
COPD
Diabetes
Emphysema
Epilepsy
Esophageal Cancer
GI Cancer
Gout
Headache
History ofPolyps
Hypercholesterolemia
Hypertension
Laryngeal Cancer
Liver cancer
Lung Cancer
Pancreatic Cancer
Pancreatic disease
Prostate Cancer
SEE OLD CHART, NO CHANGE
Stomach Cancer
T.B
Uterus CA
Age
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
Onset Age
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
Social History
Do you currently Smoke ?
Yes
No
No of Years
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
Number of packs per day
1
2
3
4
5
6
7
8
9
10
10 +
Do you drink alcohol ?
Yes
No
How much do you drink
Daily
Weekly
Are you pregnant ?
Yes
No
Other