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Text File  |  1985-08-02  |  2KB  |  22 lines
  1.  
  2.       "Date()"                                               ID :field1:
  3.                             < PATIENT INFORMATION >
  4. >>>>>>>>>>>>>>>>>>>>>>>>>>>>> Personal Information <<<<<<<<<<<<<<<<<<<<<<<<<<<<
  5. Surname:field2                        : Firstname:field4         : MI.:field3:
  6. Street:field5                :City:field6         :State:field7:Zip:field8    :
  7.                Phone:field9          : DOB:field10 : Sex:field11:
  8.                Comments:field13                                 :
  9. >>>>>>>>>>>>>>>>>>>>>>>>>>>> Insurance Information <<<<<<<<<<<<<<<<<<<<<<<<<<<<
  10.          Primary Carrier:field14   :             Primary ID:field15   :
  11.         Secondary Carrier:field16   :           Secondary ID:field17   :
  12.         Current PA:field21   :  Pa.Expir.:field22 : Assignment:field23:
  13.            Sig.on.file:field25:    Workflag:field26:   Death:field24:
  14. >>>>>>>>>>>>>>>>>>>>>>>>>>>>> Medical Information <<<<<<<<<<<<<<<<<<<<<<<<<<<<<
  15.         Doctor:field12                       : Diagnosis Code:field27  :
  16.                    Diagnosis1:field28                       :
  17.                    Diagnosis2:field29                       :
  18.                    Diagnosis3:field30                       :
  19. >>>>>>>>>>>>>>>>>>>>>>>>>>>>> Internal Information <<<<<<<<<<<<<<<<<<<<<<<<<<<<
  20.                  Status:field18: Start:field19 : Disc:Field20 :
  21. -------------------------------------------------------------------------------
  22.                             <S>ave or <Q>uit:curmenu: