- t12 et% , e--,1 .c4e 1 0 .l]-4. 4-€¦ · prepared by: spc (b)(6)-2 91w vital signs i ime bp i...

DOD 003848

iL:j — - Pio friz_

`;•••Ak- (.1"-CC

1,1 ' E., r • AME' REL A' 112 0 bPoilsori .-.---• -•.-

• ___ —• . liS(. 1 1C: N(1

RANK:

DOH:

p)(6)-4

MEDICAL RECORD

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entryl

L / 2 1-)1c . z . iyf re r—i-C6- 4

CL - ft'AI!.t ':_ rA •.-.j • / 1- ihst‘_ ___011.-t 1 .-,“ - . 6, F .1)( di4e-k-c.. 1

1 Pr_t

oC - _ T12 :A g ic, of . in, c'L A., _,:c ceepd, c C. _ , i)i _ et% , e--,1 _.C4e_1_0_.L...]-4.•_4-_______ _ __

60 Li 3 -0 - c ol

AUTHORIZED FOR LOCAL REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE

4

/Sq - 4 it&w_r_-__ A-A- _ ._ .. ._ __ . _ _. ___ 6.1._4 - .SAI.e_._,- __LI _ :4:,_ ,..ty Jr. 7,. cv__ 4.7.1c( 77,11_(•c___

- .i&. -AO .---r -- PH ` PP; i4 1 i--211:ve-. ( I G k r: ) - GrA' nc-- il.r4411-- —kf...4: :;-- 0/1.■1144"--S

C.'

S'ii. — ‘ t."5 K) idi/5 nr-.163 iii"6„/ - /36A•kr4t,, __ .0---A,...tal. 62_14tsf•--Z... ' • 'AU-4_..t.14. ' X i 3 izt-4- • 757-67.0, -, ' • iti--c

ea - No C C - . r

. . Al, c. !1/4-. A...:: 1 _

:ctii , _y/410 ,:,-)-( An .. _._(1'r kcc0e,:s.

, _ / irk. 4-‘_-__, _ _...(4 -.'L 5-1_ .6 )-_._6(.'

2- ,r,2,4_ ,3,,,,c/ 447,.. eb. gc...is ,c/ 6,,, /4 iv -

NT AINED Al

- (VI C

I sTA7US DEPART ;SERVICE ft, leill.reAlc.,(

1-ospr At OR MEDICAL .=A(.: .,.1T1

4141-7re4 .

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

SrANDARD FORM 600 (Ky. 9,0 Prescribed by GSA'ICMR

F)RMR (41 CFR! 201-9.202 I uSt• P •./:, ■_v!

. 5 0

MEDCOM - 785

"" E? 7 •

:1 • ___ _ 11

. _ . .. g 1u,41.; vs 61" G6t-_-_ c_

; .•;" drnr;/:s fs; • „

PonA 'Grade I

1.1 ■ C SIFT., NO • _ • _ . •

ACLU-RDI 1067 p.1

For Official Use Only Law Enforcement Sensiti 0079-04-CID789

AUTHORIZED FOR LOCAL REPRODUC NON

1EDICAL RECO ;D CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT. TREATING ORGANIZATION (Sign each entry)

r• APP- 04-(

/P 156

, „. ....7

6.,-,..,v1,-.:•:::,_ , • eir,/-6,7q in,,f 41,1,4 _Pi. ;

'7'38 -' . d=a_caufr.c.d.,,e..,;, fito 1,,, a _L9 17, /.1b• e., c,-4942 (4 .4 4...4-7ed ,mo i" __..

l 0 e / --/-,,,,

IS/-(-

s . P oe

- ,4) i •,

,-..tezz..,,,, 04.46( e .-ici 1 In g I c.E.4-e. v A i ( ti . f

Ab n_i ‘./ l ()Li s ey ri-64.J tic.t.i ibI 1,21,4 e. rke se in --___t_j/L;edi %.,,

, „2 ri. ; i (.-1. / ✓ CI r C et 1--C pl 11 / tif 4/ 41 ct I i kti Ir yl :..-c Si 5 /

pILZ,_e ,i-F- .. ;>,"--a.4-e-c //u2, ka s iv) 0 Ce. ire.-7 le 0 v- ..c

plec L, C Ki 1 (' e) L4/4 i 1-41 .) v) j AV rhi - ( C_ 1-7 1,:4: el CR

-V>.7.11 - i, k b)(6)-2 t ) ) - (f (,--"

b)(6)-

1

r ciii (,, ..... —t 4-0 z/ 6- A A , _. ,b)(6)-2 ---. -

.(b)(6)-2 SP, P.A.-C

ISPIT AL OR MEDICAI FAG:JR STATUS DEPARTASERVICE 1 RECORDS MAINTAINED a;

ONSDR s NAM; SSNIID NO RELATIONSHIP TO SPONSOR

IG! ,:i - L: rO T ;Tot typed et written ePpies, pive. Name • last first, middle, 10 No er 555: Ser: Vale al Birth: Rank/Grade) REGISTER NO I WAVY OC

(b)(6)-4 CHRONOLOGICAL RECORD OF MEDICAL CARE

Medical Record STANDARD FORM 600 !REV 69:

Prescribed by GSA/ICMR FIRMA ;41 CFRI 201.9 202.1

For Official Use Only Law Enforcement Sensitive

•

MEDCOM - 786

DOD 003849

ACLU-RDI 1067 p.2

Prepared By:

spc (b)(6)-2 91W

Vital Signs I ime BP I Pulse Resp Pulse Ox Temp GCS

i I to fp,

[

Transfer Instructions:

NOTES: r- ,4 c.a

Q ,11h1215 9 8 G 2 3 5

)! — -

T— --410-79-04C I D789

Blood Components

. Unit # Type Time I Responsel

I

I I 1

cial cenliiTSen

For Ofi Law Enfo

Brcdthin 1;. L

(- irculahon: t_

Other:


MEDCOM - 787

DOD 003850

ACLU-RDI 1067 p.3

ji

•

L., I z, • , 4'6/1 , .• • 0. -For--Official-U-s-e-044

f 9W Knforrement Sensitive 0079-04-C1D789 (b)(6)-4

yi VI X : i i Air,

S H X : I" 13 , ,...._, 0.44reath-ing. pontaneous Assisted by

I eds: 3 i' o-s,... :1 c (1:14, „I 1 Circulation:

l Pulse: Absent

iergies: (4 e„,„

Color orn Abnormal

Cap refill: 3e layed

Secondary Survey itial Vital Signs: bio igq /12.51 pulse q8 ResnAPulse Ox I/ Temp 78.9

Primary Survey echanically maintained hy

CPR

Ak I

Revised Trauma Score CLASCOW

_COMA

EYES OPEN

Spontaneously C;LASCOW COMA TOTAL To Speech 3

13-15

II; "

(1-8 r 4-5

76-S9

50. - 5 minHe

i mmHg

To Pain None

Oriented

4 SYSTOLIC BLOOD PRF.SSLRE

BEST VERBAL

RESPONSE

L BEST

MOTOR Localizes Pain III-2PONSE

Flexes to Pain

Fxtends io eltin

None

Kir A I_

I (1-29

oisrl

f,••1

T .

I Z„

R ESFIRAtOR Y RATE

Confused

Inappropriate sound.: 3

Incomprehensible 2 dc soun

None Obeys Commands


MEDCOM - 788

DOD 003851

ACLU-RDI 1067 p.4

DOD 003852

DATE

2A-p r ç L-1 1

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each anti),

REPORT OF DETAINEE MEDICAL SCREENING: •

History of' Past Medical Conditions: (circle) High Blood Pressure. Diabetes, flean Kir'Failuri.s. Seiztires. Strike.

Chronic Bom,e1 problems. 1 . 1ix jud

Medication Allergies (NO) 'ES) List -

Current Medications: (Name/Dose/Frequency/Last Taken) (NONE)

RECORDS MA.r..!:- HOSPITAL OR MEDICAL FACILITY STATUS , DEPART :SERVICE

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SSN/ID NO

MEDCOM - 789

••■•• bar No,

For Official Use Only Law Enitorcemen CHRONOLOGICAL RECORD OF MEDICAL CARE MEDICAL RECORD

Recent Injurits:'4O

Exam Finding : BP: _19) Pulse: Resp: Pt,,k76- 9-4 cye, —1 9

I.

• • • • - ti I ize Ditturat and Space BeloA to Indicate Examination Findings.

IT AMR ace required:co-MI-nue on reverse

(FI1) (UNFITi For Confinement

(Does) (Does ou Require Further Eva!

Name/Rank/ nit of Screener

YES))escue

1 S IDENT! , !CATION

Detain e. x.tnie:

I.)ate 'lime or Detention:

REGISTER NO

CHRONOLOGICAL RECORD OF MEDICAL ;.; Medical Pecu

STANDARD FORM 600 Puesonbed by GSAJICMI< F!RMR (41 CFR ; 201 , 9 '

(For :yped or ...r..tr,:r...?Ignes, 9;ve Name • last. las! ,mddie ID No or SSA; Se:, Date oi 001, RanK,G ,ace

(b)(6)-4

last. ! irst ontroI N umber. - 3

o

AU THCOMFtptteXylrg9 : •

[\ e r LA For Official Use Only

Law Enforcement Sensitive

ACLU-RDI 1067 p.5

Revised Trauma Score

[GLASCOW COMA

EVES OPEN

BEST VERBAL

RESPONSE

BEST MOTOR

REPONSE

Spontaneously

To Speech To Pam

None Oriented

Confused Inappropriate sounds

Incomprehensible sounds None

Obeys Commands

Withdray...f..to part ,

Flexes to Pain

Extends to Pain

' TOTAL _J None

5 4

1

Localizes Pain

GLASCOW COMA TOTAL

SYSTOLIC BLOOD PRESSURE

RESPIRATORS' RATE

13-15

(Li 7

6-8

4-5 3

>89.mmHg.

76-89 mmHg 50-75 2

mmHg 01-49 1 mmHg

No peke 0

10-29 min

-29 mill 6-9 - min 2_ _ 1-5 .•.!ni

Non,: (I

r TOTAL : 4/1

,r1r ,

PM H X: Airway: a Ate4.:.an i call y maintained by .

PS FIX: 't t??, —...Lic_rarlitereathittO. pontaneotit) Assisted by

M eds: 3 i' 0-cic pie ,4 Circulation:

Allergies: i_L e.,„ rA. Color: Pulse: Absent

bnormal

CPR I

Cap refill: o elayed

.Secondary Survey Intial Vital Signs: bip (64 1- 2,5— pulse ci Resp t Pulse Ox 14 Temp M.9

LAD:

NECK:

.1::

' NCIS•

- HST•

A 13D: r

fli

; •

1

Pri11121i-T EarV'

MEDCOM - 790

DOD 003853

ACLU-RDI 1067 p.6

Circulation: L

Other:

Vital Signs B/P I Pulse Pulte Ox Temp GCS Time Resp

NOTES: Fi -t O. & 8.4

Blood Components

Unit # Type Time Response—


Prepared By:

SPC b)(6)-2 91W

MEDCOM - 791

DOD 003854

ACLU-RDI 1067 p.7

- .„ ....... ., . . . .,

DATE ''"' : ,̀l SY1%.,W1INS, DIAGNOSIS, TREATMEOT. TREATING 914 ::.z.fiTIOio f,5,;g5.mc...

, i .-'? (- f.".'.. u: • { / i . ., ' • t I-272 ,...2 ,.., _ 71; 1_..(,) C.) __.. ,- (-, (A 1/6,11), /7

Li /

. <, i' ,- ..- — 'I) 1 / . •:. ; , .

P 1,726 /

s: . ,-....-,, ,-.. 1 , (_' — -,A4 ,--; , - •

) , . ,

7 -- ri r. ,i4 y

, , ....., • _ __ . _.............

cA,zei . i

f.,

P /O 0 i e ale 5 P " ,--.„_,..41,,/- clod e_ ii____.!_csi 1,1,, la4-e-v,-I. t ( . v _ / ....k__16,2___ i • ,..

._ .1 ■ -

j ..e ' I ji 14

pt-14. 447. i/1÷- .. ..›Vtafik- S tuv LUL t,

yvoq , 4.; f r' /7 tivit. 4-(p; 0" — •t • ci4 4

ba-e- i., 4 4- . -ar • b)(6)-2

66:--r- ----'- b)(6)-2

....— .

..._. - , (b)(6)-2

SP, P.A.-C

HOSPITAL OR MEDICAL FACILITY STATUS DEPARTISERVICE RECORDS MAINTAINED AT

SPONSOR'S NAME SSNII0 NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: (For typed or written entries. give: Name • last (irst, middle; 10 No or SSIll; Sex; Date ol Birth; Rank/Grade.) REGISTER NO. I WARD NO.

(b)(6)-4 CHRONOLOGICAL RECORD OF MEDICAL CARE

Medical Record STANDARD FORM 600 (REV. 6 971

Prescribed by GSAIICMR FIRMR (41 CFR) 201-9.202-1 USAPA 57 Oa

9

MEDCOM - 792

DOD 003855

ACLU-RDI 1067 p.8

Ad Cf 0(319, (b)(6)-4

PMH X: PSH X:1" RP, Meds: 3 1740F'J Allergies: t.4.1

.Secondary Survey tuna' Vital Signs: b/p 494 OS pulse /8 Resp_16Pulse Ox }1 Temp 72.9

.;EN.

NECK:

it NJ:

- NiriS•

-HEST:

a tea 17 --'•■•

.

:FLi Al.:

\10

Fl Pi:

Primary Survey Air.vay: hanically maintained by

wreathing peritonea) Assisted by

Circulation: Pulse: 11.111..115t Absent CPR Color: =-1-1 • bnormal

Cap refill: 4 errriabelayed

Revised Trauma Score

CLASCOW COMA TOTAL

12 6-8 4-5

3 >8%mmilit

SYSTOLIC BLOOD PRESSURE

RESPIRATORV RATE

76-89 mmH 50-75 mmH 01-49 mtuR

No puke 10-29 r min

•-29 3 6-9 min

1-5 min None

TOTAL LI Z-1

L P41 • •

CLASCOW COMA

EYES OPEN

•

Spontaneously

To h 3

To Pain None

BEST VERBAL

RESPONSE

Oriented

Confused 4

Inappropriate sounds 3

Incomprehensible sounds None

BEST MOTOR

REPONSE

Obeys Commands

Localizes Pam Withdraws to Pain

Flexes to Pain Extends to Pain

None TOTAL

MEDCOM - 793

6

DOD 003856

ACLU-RDI 1067 p.9

SPC (b)(6)-2

Response] Time Type Unit #

Ione On:. L)ose Rowe I relp!S

N...0.1 '

. , .

J

Blood Components

Time B/P Pulse Pulse Ox T GCS Vital Signs

ir


Prepared By:

, 91W

NOTES: f:,.4

•

Circulation: t M L.

Other:

0.13-0q- coD I q

nc, f

•

F,)

MEDCOM - 794

DOD 003857

ACLU-RDI 1067 p.10

PATIENT'S IDENTIFICATION:

(b)(6)-4

(For typal wrirrta 'Wits, Or: Name • Iasi ffist nc ID No ot S.Sit SFr; DAN ofiterk Rsakerldrl — T REGISTER NO. PiANO NO

CHRONOLOGICAL RECORD OF MEDICAL CARE Merkel Record

STANDARD FORM SOO (REV. 6 -971 Prescribed by GSAI1CPAR FIRMR 141 CFR, 201-0.202-I USAPO. V/ 00

oiiEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE OJ jO I4

DATE --...„ ________ DIAGNOSIS, TREATMENT, TNEATINU Uk._,...tLA I IUN Gwyn each entry'

s'rkii 004,--04c. . f:4 y c eV+ evr 4 ;Oa 4.1,46(I

i/Apk. O.( _, 7 v

.._,A4cit /10

'pp p, —/E /56* --I qg - 'r' dzle_cd,3 i) ,,Pec.4 h a I., I ,1cMc - L- 5 fire)

P /0 0 i ,0 5 r° 4

r

(1.17 emd e If act/ Ili icw.4-ever. r c y . ..4'

iiin nil 1 , b-j:I e> pe s l u I oi) 5 0 4.1°_,/ tirzi l ot

4

'CA I plee,(

.. , ,..A1• a. if-, . •

(LT) V1/4A1 C +ifei /4 5 411/ r. f I (4 i c.j4 IA,- liot .c, •

foal'. I•I The-JI LT* -Kee ''

91 (A) (b)(6)-2

A •

C • 17 rc A i . A 40 6 ' e ' - (b)(6)-2

/.. (b)(6)-2 SP, PA,C

HOSPITAL OR MEDICAL FACILITY STATUS DEPART/SERVICE RECORDS ALAIMO/ED AT

SPONSOR'S DAME SSNIID NO. RELATIONSHIP TO SPONSOR

r cl L

c

MEDCOM - 795

DOD 003858

ACLU-RDI 1067 p.11

SAP ,i37

For Official Use Only 1_,sw Enforcement Sensitiv't' 0079-04CiD789

AUTHORIZED CCM LOCAL ELEPRODUC


SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (So each way)

( (-q I - 1-;-. v --T _A • • ► trIP : I,

, ■ . t f 156 .,... ••

-t-1- 4', • oiL . • ,,,,,,6 , ' AP .0 • ,,,,,. , ..,, • , , __ _

. 5p0, , , ,. • - , _, ,_ • . P lc c>

.g,__ /4.2 I, • . .. _ • 4. . a

. • ...,

s ..

...." a 6. I t - - - .c CLI A — . - i - - i g., • , .

1 A r1. is , L!( - 1 a A A , ...

_ b)(6)-2

f.-(70

ii et. ....

A. . i (b)(6)-2

/fiNST (b)(6)-2 . SP, P.A.-0

.._ _

MEDICAL RECO I/

OATE

,SPIT AL OR MEDICAL FACILITY STATUS I DEPART JSERVICE

SSNIID NO

:ypod I vaiwn erVries. o,p: • 4V. Alt, IC PO a 5.511: SPx: Cite el lark RankiSmia.) REGISTER NO .

...1*00••••••••

1 RECORDS MAINTAINED Al

ONSOR'S NAME

N1 "S 'Or N A' :ON

RELATIONSKP TO SPONSOR

(b)(6)-4



Medical Record

STANDARD FORM 600 MEV 5 97.

Prescribed by GSA11CMR FIRMR 141 CFR) 2E-9.202

MEDCOM - 796

DOD 003859

ACLU-RDI 1067 p.12

----1 --pe79-641.

illse Only , mst senittiv*I—s"" 1D789

For OfciM Law Enfo cem

Breathing: L

Circulation: t— M t_

Other:

Blood Components

' Unit # Type Time Respouse

•

Vital Signs Pulse Ox

i0

NOTES: p=',4 Q.k

Transfer Instructions: time

BiP Pulse Resp GCS

Prepared By:

SPC 0)(6)-2 9 I W

For Official Use Only Law Enforcement Sensitiv

MEDCOM - 797

3

J

DOD 003860

ACLU-RDI 1067 p.13

It 1 -1]

N

None TOTAL

CLASCOW COMA TOTAL

3

-S9.mmHt

76-S9

L 50.75 ! 2

mmHg

L111-44

mmHg

Nei plikv

1 1(t.29 • min

RESPIRATORY • .9

RATE tom

, Revised Trauma Score

To S To Pain

None

Oriented

Confused Inappropriate soindi

Incomprehensible sounds . _ None

Obeys Commands

CLASCOW COMA

EYES OPEN

BEST VERBAL

RESPONSE

4-12 (i-8 4_c

SYSTOLIC' BLOOD PRESSURE

BEST MOTOR

REPONSF.

Localizes Pain io Paw

Flexes to Pain F..xtends to Puin .

• N4 on,. • .

ro. !

I 04k, 0079-04-M*789 co.

IPI

simmeitiv i La1(b)(6)-4

Primary Survey

•VIHX:

'S X: 't t3F. ,

leds: 3?0,441c, Pelovj

Alergies:

Airway chanically maintained by_ _

%kitreathing pontaneou Assisted by_ __

Cuculation:

Pulse: ØIt Absent CPR

Color: • bnormal

Cap refill: 10 elayed

ntial V ital Signs: bip af . pulse 9'8

Secondary Survey RespA_Pulse Ox 11 Temp


MEDCOM - 798

• 1

t 3

DOD 003861

ACLU-RDI 1067 p.14

nit of of Screener

HOSPITAL OR MEDICAL FACILITY

'Nunn/Rank! STATUS DEPART /SERVICE RECORDS IN1:-..N: "

IVIEUICAL RECORD

tw f • • ,•••

For Official Use Only N1----EffEnfaTniarat-Sertsitv10#1 AumWSWWW10701,30(A


DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

12A-pr c)1-1_ REPORT OF DETAINEE MEDICAL SCREENING: -

History of Past Medical Conditions: (circle) High Blood Pressure, Diabetes, Heart Failt:ri:. _ SIae,

Ulcers Chronic Bowel problents.1hrp,1 1)2

Medication Allergies (NO)) ES) List -

---- —

Current Medications: (Name/Dose/Frequency/Last Taken) (NONE)

n 11 Recent Injuries: NO YES) esc ribc - f_SH--n c. eir.5

ResP: 1 \‘ 5 ot 0 )C 9-4- °le) (95

• BP: .0) .1- / 12- Pulse:

and Space Below to Indicate Examination Findings.

Yeifiti-7C-eblittfitte-011

Exam Finding :

Utilize Diagrat rfdi1idifl -I

(FIT) (UNFIT' For Confinement . _ _

(1)_ocisji_C__foes cill.:equire Further Eval _

SSNAD NO RELATIONSHIP TO SPONSOR

Detaine

L. )III!-01 Number:

_

L,OSt, Middle

Date ri ime Detention.._ For Official Use Only

Law Enforcement Sensitive

MEDCOM - 799

SPONSORS NAME

PATIENTS IDE NI iqCAT ION (For woo or wrioto enrries. give. Name - last first. middle: 10 No of SSN. Sex: Date of REGISTER NO VYF.R0 N.:

Bern RarotiG ,acte - - CHRONOLOGICAL RECORD OF MEDICAL CP Kt.'

Medica! Record STANDARD FORM 600 OREv

Prescribed by GSAfiCMR FIRMR (41 CFR) 201.9 202

DOD 003862

ACLU-RDI 1067 p.15

- t12 et% , e--,1 .c4e 1 0 .l]-4. 4-€¦ · prepared by: spc (b)(6)-2 91w vital signs i ime bp i...

Documents