My Health e Vet

Personal Information Report

Produced by the VA Blue Button (v18.4)

** *** **** @ 1932

This Personal Information Report is a copy of information that you have selected from one or more of the following:

Your Personal Health Record - Health related information that you self-entered. Key information from your official VA medical health record. Please contact your VA health care team if you have any questions about this information or if changes are needed. Information from your Department of Defense military service record. This report is intended for your personal use. It is not shared with VA. Portions of this report may contain sensitive personal health information from your official VA medical record. Protection of the information contained in this report is your responsibility and of those with whom you choose to share this information.

NOTE:Your Personal Health Record does NOT contain all the information from your official VA medical record. If your VA medical center has transitioned to the new electronic health record system My VA Health you can access your medical information at www.patientportal.myhealth.va.gov . If there is medical information not available to you online, contact your local VA facility Release of Information office.

Key: Double dashes mean there is no information to display. Name: COTE, TRACY MARION Date of Birth: 05 Oct 1967 COTE, TRACY MARION

Date of Birth: 05 Oct 1967 Page 1 of 6

Download Request Summary

System Request Date/Time: 13 Nov 2023 @ 1932

File Name: mhv_COTE_20231113_1932.pdf

Date Range Selected: 13 May 2023 to 13 Nov 2023

Data Types Selected: My HealtheVet Account Summary Self Reported Allergies

Self Reported Medications and Supplements

Self Reported Military Health History

COTE, TRACY MARION

Date of Birth: 05 Oct 1967 Page 2 of 6

My HealtheVet Account Summary

Source: VA

Authentication Status: Authenticated

Authentication Date: 16 Mar 2023

Authentication Facility Name: AUSTIN MHV

Authentication Facility ID: 200MH

VA Treatment Facility Type

X BOSTON MA VAMC (523) VAMC

X TOGUS ME VAC (402) VAMC

VA CENT WESTERN MASSACHUSETTS (631) VAMC

Note: The X represents your self-selected VA Medical Center preference. COTE, TRACY MARION

Date of Birth: 05 Oct 1967 Page 3 of 6

Self Reported Allergies

Source: Self-Entered

No information was available that matched your selection. COTE, TRACY MARION

Date of Birth: 05 Oct 1967 Page 4 of 6

Self-Reported Medications & Supplements

Source: Self-Entered

This My HealtheVet Pharmacy module contains self-entered prescriptions, over-the-counter products, and herbals/supplements YOU entered in your My HealtheVet self-entered Medications List. Your VA health care team CANNOT view this list. If you would like to share it with your VA health care team, print this list and bring to your next clinic visit. Category: RX Medication

Drug Name: Lorazapam

Prescription Number: Start Date: 22 Apr 2023

Strength: 0.5 Stop Date:

Dose: One tab bid prn anxiety

Frequency: Bid

Pharmacy Name: Northern lights

Pharmacy Phone: 207-***-****

Reason for Taking: Panic attacks

Comments:

COTE, TRACY MARION

Date of Birth: 05 Oct 1967 Page 5 of 6

Self Reported Military Health History

Source: Self-Entered

No information was available that matched your selection. END OF MY HEALTHEVET PERSONAL INFORMATION REPORT

COTE, TRACY MARION

Date of Birth: 05 Oct 1967 Page 6 of 6

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