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Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: MD HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YE

Exp. Dale: Exp. Date: Exp. Date: Exp.. Date: Exp. Date: nrilartiletriailiTtheiii3Oataiiiiiii:Ilii ,77:; .- • Start Date End Date 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. !fla;:a-)ciaetaitat7 - Cleared for Food Service: Yes • No Restrictions Comments: N/A MD 07/3

uma Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEAR

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

ervices. SUBJECTIVE: COMPLAINT 1 Provider: Beaudouin, Robert MD Chief Complaint: ENDO/LIPID Subjective: 66 YR OL HITE MALE WITH HX OF HYPERT CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS • EIR GI SIDE EFFECTS. HX OF

other: Exp. Date: May have the following equipment in his / her possession: Equipment Start Date End Date Return Date C-Pap 07/30/2019 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Comments: N/A

uma Date Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEAR

ap. Date: Exp. Date: May have the following equipment in his / her possession: Equipment Start C ite End Date Return Date C-Pap 07 ni 19 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Page 082 of 148 Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions

Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: MD HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEAR

: _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

Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: MD HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEAR

: _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

uma Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEAR

_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

uma Date/Year: Injury: Mechanism: Onset: Duration: Exacerbating Factors: Relieving Factors: Reason Not Done: Comments: HITE MALE WITH HX OF CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE EIR GI SIDE EFFECTS. UVE SLEEP APNEA X 5 YEAR

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