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rt MD Us. Eg. Waist Circunt, Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unkejii• '•fi cutely III Nutrition No: Appears On

equipment ,other. Exp. Date: AYTPREirgEffirelartlitrriTittailiiiTtiziailiiiiciliiitiU ; • Equipment Start Date End Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL tt: P113121313B1ED. WO 110 • Wir .r. s'ziff : :Xie<; . :fr ; • Cleared for Food Service: Yes X No Restrict

88.1 MD Lbs Kg Waist Circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary

ketball _handball _stationary equipment other: Equipment May have the following equipment In his / her possession: Start Date C-Pap 07/30/249 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. .%i% SERIAL #: P11312813B1ED. Work Restriction I Cleared for Food Service: Yes X No Restrictions Comments: N/A Beaudou

88.1 MD Lla Kg Waist circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unke Acutely III Nutrition No: Appears O Pulmonar

: _football _basketball _handball stationary equipment • falergiffinagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. O W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A 1rtatts:Iriart He

.2 88.1 Lla Kg Waist circum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unke Acutely III Nutrition No: Appears O Pulmonar

_basketball _handball stationary equipment • falergiffinagra urS areigiga nieig (Mif; •';' Equipment Start Date End Date Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Cleared for Food Service: Yes X No Restrictions Comments: N/A Health Services Staff • Exp. D

4.2 88.1 OA Ku Waist Qircum Provider Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distre ed. Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic. Disheveled, Unke Acutely III Nutrition No: Appears O Pulmonar

ther: _football _basketball _handball stationary equipment • faletanagra urS areigiga niiiiig •';' Equipment Start Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. W m tali Cleared for Food Service: Yes X No Restrictions Comments: N/A ttiatts:niart Health