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Solfelt \ . ��F NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota y0�i l��a > Minnesota State Statute 466.05 states that "...every person...who claims damages from uny municipality...shall cause to fie pres the '�G governing body of the municipaliry within 180 days after the alleged loss or injury is discavered a notice stating the time,place,un � circumstances thereof,and the amount of compensation or other relief demanded." ��,�� Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you wilt not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name�'��_ Middle Initial ✓ Last Name L. � �OVI/�� GC, �,�la-- n5� nim. �. r.� ; .n-�r�s-�T 35�-8 Are You an Insurance Company? Yes/ o If Yes,Claim Number? y�,►�u Nd� av : �5 r�P� Street Address City ��7 � Y�}"� L State � /�/ Zip Code -�J/ � Z Daytime Phone( ) - Cell Phone��_��j��ening Telephone(�j��—�Z� Date of Accident/Injury or Date Discovered �O/� Time //:�C� am/�� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. F � � Please check the box(es)that most closely represent the reason for completing this form: ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow ❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow �My vehicle was wt'ongfully towed and/or ticketed �was injured on City property ❑ Other type of property damage—please specify , ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all apulicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WII.L NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt � O Other property damage claims:two repair estimates if the damage exceeds$500.00; or the actual bills ; or receipts for the repairs;detailed list of damaged items �� jury claims: medical bills,receipts togra�hs are lways welcom to document and support your claim but will not be returned. —3P�d�s ' /�d�� rQe�r�'� ' Page 1 of 2—Please complete and return both pages of Claim Form � _ I t Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were there witnesses to the incident? � No Unknown� ircle) Provide their names,addresses and telepho�e numbers: ` U Pr SO <3 I � � � �L Were the police or law enforcement called? Yes � Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detai ed as possible. If necessary, attach a diagram. �-� 1-^s�2A//V'��LFi IQ�/�'Q��,/ �— L�t'I.C�- o2gy SPRIN . s ST: .�`T' P�U�- �7'� . b�. /D ,/ � lease in d�ca te t he amoun t you are see n in compensa tion or w ha t you u l d It ke t he C�t y to d�o reso lve t his c laim your satisfaction. G� ` e ` � � � r'Gt /�f,A,�° -' n°�°-�p�'-� `� �� .� Vehicle Claims—nlease comqlete this section ❑ check box if this sec�ion does not applv / Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'u Claims— lease com lete this section ❑ check box if this section doe not a 1 How r you injure ? L/ � G t�N !'�Q �h h S �n / � Gti I /U � S Wh t part(s)of your body were in'ured? j E FT IGOo T � (�i��{/E�U S��FEL f_3O�urG� Fj� Q 'D 4F D ' �r� Have you sought medical treatment? es No lanning t Seek Treatmen 'rc ) `n.. �� When did you receive treatment? � � .'+O/ • � (�prov'i� date( )) �,e_ Name of Medical Provider(s): � � ' '�'�q��' Address S L G 50!'`� lephone `v Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer. ' Address Telephone Check here if you are attaching more pages to this claim form. umber of additional pages , iP�LCi p� � r�eo��`cer� �c-��r,r�� '' By signing this fornz,you are statcng that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �/ —/ � �fE,G � P $ � I Print the Name of the Person who Com leted this Form: � 5ignature of Person Making tl�e Claim: , � I Revised February 20ll j � � I I November 26, 2012 Description of Tncident: On June 3�d 2012 at 11:30 pm my husband and I went for a walk on the path along the Mississippi River at the Upper Landing area in down town St Paul after he got home from his work as an orthopedic surgeon at Regions Hospital.The City of St Paul was remodeling the historic grain elevator in front of our condo at 284 Spring Street. The lights were left on inside the area being worked on and I stepped up the one step to look inside the large glass door to see what was being done.When I turned around to step down my foot slippetl off of the edge of a metal ramp that had been left by the workers probably to use to get their equipment up the one step into the building, causing fractures of my left foot. My husband assisted me home by car because I could not walk.This is a public area antl there were no safety cones to draw attention to the ramp,or other signs of warning of its presence or means of preventing stepping off it accidentally.We often walked in this area and have stepped up to look or enter the building, but this time the ramp was unexpected and I didn't notice it as I stepped down in the dark. I have attached photos of this site.The photo shows the ramp without any protection near it, and in fact they show other areas of sidewalk that had been removed and were not protected either. The one cone on the left was just randomly left there from the work done during the day and not near the ramp.This photo was taken a couple of days after the injury by my husband, but I remember looking specifically that night after I fell and before I got up to see how I could have missed seeing the ramp and there were no cones anywhere near the ramp or signs to prevent access to the area. I called the City's complaint department a short while later to alert them to the danger of this ramp and to notify the contractors of what happened so they could take measures to correct this dangerous site. I feel the City of St Paul is liable because they hired the contractors to do the remodeling and that company did not take the precautions necessary to prevent this type of accident.The ramps were not permanent and should have been removed after work was done each day, or at least blocked off to bring notice to their presence. I have health insurance that has covered most of the costs of my foot fractures but feel the City should be responsible for my out of pocket costs coming to $393.41. I have attached medical records and copies of , the receipts of the costs I had related to this injury. I still have some nerve pain,but hope this will resolve with time. We are moving on Nov 30 to Madison WI. Our permanent address is Barbara Solfelt ' 3526 Timber Lane Cross Plains WI 53528 I li �� I �i I i.: �., �� ;�. �, .. ��;i ;� :2< �� : � � �;4 � � , � � � � �_ � �,,� �� ' � ,� � �w,�, � �� , ��s,d �, �. � .� � a� ,� ; F � � � ,�.� 4� ��.�,r �f�v,'i .� . i5 ,�'� w"��' `f ;�"y �� '��, � h4e � �. M F I��i�`� �I�i� � y " � ��! Jd��,w�• �� ,ti� �� I!�0��1'Ill��il�a� �`� �� u� � _ � at �` �� c .�" a � � ; �. 4 �� # ��Ta�... � �.�:� °��, '� �3„�.. � ��r', . � �, IfVrl� ..,� �� e . t'= I�II � s"� z. 7 I u I^I , `� � c��n � ,K'��, ; ��p�e °��r 5`��; p � � `�� ` xia �^3,'� � �1�a M5' ��. 4�*:b 'M,�� I ��t I ��Y � � �.;, w•"� ,°-2�.,.r�*,., �� ... �,,, I s�:m � :t � L y � , J. .. . . . ��.. . � .„ ., _ ,,� � ,:,�. ;:;`° �� x � � � � �� - �_ �, �:_ a_ �e _ >� , . '� �� . �' .*r-.. . . . . . : e -4��.� . .. . . `'�C+ . � . . ,� , f . . .. .. . . . . � e t+' ^ t.: �.• ..� � . � . . :'+f' . '1.as _ .. . :z� r _. _ , ,. 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Branch Office:��can Healthcare 6 � HIPAA Signatu2 on file:No '�'W' , Mobllity 'Healthcare, DOB:2N9/1953 ' DOD: �, Weight:Iba. , Account: �,Inc. ,�:' Mew Saies��6edar �''� �Mtrw fickuqtExchauagx �DaYaza ,....._..._... �.w:....�,�....�_._��__...,..__.....:..._.....,_,._..�....:::�_�_..-��: Summary Personal Contads Ciinical Insurance Notes Financial Orders �ustom Fields Documents History Financial Inv_oices Aged Balances Unapplied Payments Denials SWtements Payments on Account Invoices(6 Records) Criteria _ ToWls : _ '. Inv.Statua �[AII] . ...... ., �'.. '�, Tofal Clwrye f1,317.00 Tofal Allowed 51.028.00 ��. Insunnce [All] .. .. ... . . ' Tohl Tax 50.00� Tofal Adjuslments t5t9.70 ��... .. ......... -.�.. �. ..._.. ...... . + � . �, Total Payment 5797.30 Totel Balanee 50.00 '�.. ,_... . _r ...._ ..� _.... ... .._... ...._.. _..._ ....... �__.. ..., , . _. ._..._ .._ . Inv# �Inv Status 1 SO# Insurance DOS Open Dt _Charge i Allow� Tax: Ad�� Pmt Bal � . .. ... _.._ _._.. . ...._. ._. ._._. _ .__... ._._..... ..._.. ...� .. . _... __... ._._ ... � ; 17651 Closed 4772 MEDICA 7/7/2012 7/20/2012 E89.00 E89.00 . y0.00 . E89.00 0.00 5000 j � 17652 Cbsed 4772 [Patient] 7/7/2012 8/13/2012 50.00' f0.00 50.00 E0.00 50.00 f0.00� - - ! 3fr174-� Cb:ed�... i772 . A4EIXE.4 ..� . 8/7/2012 81712412-- - 389.89�, .. SA900 �' EO.pq' -. . S89A0 . _ SO11��-- SO.QQ.1- - ;.- __.... __... .._.. ......_ ......... ......... ......._ ......... . ...... .. ... � - . . . . . . . . ... _.. ....._ . . .._... ..._.. ...... ... ......... ..._.. .. 18175 Closed 4772 [Patient] 8/7/2012 E0.00 50.00 50.00 50.00 50.00 5000` 19413 Closed 5214 MEDICA 8/7/2012 9/17/2012 f1,139.00 5850.00 50.00 550 E637 50.00! /; - 19414 Closed 5214 [Patient] 8/7/2012 9/28/2012 5000 f000 5000 (E15946) f15946 5000� �.. .._.... ...... __ _......_ . _ _. ,,.,�. _._ . _._. �..��. .. _,..... ..� �M..� ..._�... ,...., . _. �.. . � ._ .. N i �`( 1 > ; 1I=' Pagesize: 20 ��'l C�' ��r,1 l �� ►� 0 (/�� G�S-e � _ 5g 1 �� _ i Summary Personal Contads Clinical Insurence Notes Financial Orders Custom Fieids Documents History �2012 Brightree LLC.All Rights Reserved. i � I I � https://b.brightree.net/61/0102/CwHC/Patient/frmPatientFinancial.aspx?PatientKey=1898 11/5/2012 �� . .�€?a;,;,�.a ��-d�� c.. � ..n:�.�tM:l."; ., a�f.IFiM'+�,:��•:s4'.,. .v:�$ie�., ... . , � .L � �^'�..}> yw,��._... �L ^°{Iy�P • �^� � � ��i.�� .+.. � • � � A � � �M.FP::�'w;:��, ' .. .. .. � � �Y.:�� CW Healthcare Inc 4301 QUEBEC AVE. NORTH SUITE #3 NEW HOPE, MN 55428 Invoice (763) 535 9929 �Yt�rl C�� // /��j)1l y`Y -�►-��`°"��fj eQ� Customer Misc BARBARA SOLFELT Print Date 10/1/2012 284 SPRING ST#107 First Print SO/1/2012 SO ST PAUL,MN 55102 Invoice 19414 Order 5214 Account No. , ` ,. �,�...�.r. ��p�k��n ,i , ., : ; �G#�ar�s�l�e �+ay�� . � � �._. ._ . � - - - , , 1 08/07/2012 KneeWalker6595U - $�,i39.00 - - Knee Walker 08/07/2012 Write-Off Allowabie $289.00 I 10/01/2012 AdjustAllowable I I $52.70 I I I 10/01/2012 Payment I I $637.84 I Total $1,139.00 $979.54 Balance $159.46 Payment Cash Check Charge PAY THIS AMOUNT: � / �159.46 Comments Name CC# Expires BT-INV4-11891 Page 1 w Credit/Debit Card Transaction Page 1 c ' r�GE.INA.�-iC��i��; ' �. C�7ht�4�..�''31�'1' S�R't�1�F� ?,��:.;,F€<g�i�ul��t tir,u> � Allina HOME Web Payment 2925 Chicago Avenue Minneapolis,MN 55407-1321 (612) 262-1700 .tient First Name : BARBARA tient Last Name : SOLFELT �ME Account Number : W1937 �edit Card - Sale --- APPROVED --- :sponse Message : AYPk�>VA;� �sponse Code : 000 �p 13 201.2 10:57:23 AM rd Type : VISA ��d Holder Name : BARBARA J SOLFELT Td # : ************5905 .th Amount : $35.35 .th Code : 01741D AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO MY CARD HOLDER AGREEMENT. I �ignature) � j I Thank you! ' _ U"�"�-'L� - ' `.� � ��l �� r ►s://paymentnavigator.usbank.com/Forms/PatientPayments/V iewCreditCardTransactionForm.aspx?Tab=Recei... 9/13/2� � . i I � i � r I �,. . . _. . f � _ . -. _ __ i,� e : .;t � � .;z�41', �''��{♦�l�M+4 N�y �'`�y '�Mi� � . .�� J� yy R � •� 'wsn - . ' ' i � . h ALLINA ORIGINAL INVOICE �: .'.. '. . ..:.-. - , HOME OXYGEN& 'MEDICAL EQUIPMENT i . 06/12/12 W1937 02704126 _� Allina Hospitals&Clinia - — . � � : • Circle one: � � � . �• '� Card Number SIC Amount Authorized Exp Date ALLINA HOME OXYGEN MEDICAL EQU Signature PO BOX 9344 NW 7365 MINNEAPOLIS MN 55440-9344 AMOUNTENCLOSED$ (612) 262-1700 FAX: (612) 262-4088 p�ARBARA SOLFELT H �BARBARA SOLFELT p284 SPRING STREET P 284 SPRING STREET UNIT 107 UNIT 107 � SAINT PAUL MN 55102-3267 � SAINT PAUL MN 55102-3267 Please remit top portion with payment rORDER NU�dBER ORDER DATE CUSTOPAER ORDER NUMBER LOC SLS# TERR p �HIF�VIA TERMS iai7iA�s PAGE 03039491-00 06/08/12 NEW-I UNI MTO METiPICKT7P UPnN-sy'C��n^.` Lp;vd 1 � � _ __ - i � ITEM s�,PO �o DESCRIPTION UOM PRN�E AMOUNT RELEASE #: UNITED PICK UP ' ** Balance Forward ** 0.00 ** Location: I ** RNTDRI790 1 WALKER KNEE DV8 300LB MTH 179.00 179.00 EA DRIVE HANDLE HT 33"MIN 38"MAX MEDICA CHO 80$Y 143 33 i Allow: 179.16 TAdj : 12.5300 Tax: 12.6900 Patient portion: 35.83 A R#:00706890 #: ST:06/08/12 EN:07/07/12 R :N SETUP 1 ONTH and 0 DAYS A#:00585728 NOTE: THIS MAY NOT REFLECT YOUR ENTIRE BALANCE. QUESTIONS? PLEASE CALL 612-262-1700 OR 1-800-737-4473 OPTION 3 www.allina.com/PayHOMEBill Subto al 179.00 � _ , � _.__. _ _ i — _ , Cash/Dep R ceived 0.00 � PA BLE U ON RE EIPT - NO CREDIT Adjustm nt 12.53- IS ED FO PART AL PAYMENT I i I ax 12.69 Subto al 179.16 027 - MEDICA CHO CE 143.33 TAXABLE AMOUNT p�✓pQ��( ppq¢3'3rW. PAYABLE UPON RECEIPT • � 3 5.83 Make checks payable to: ALLINA HOME OXYGEN&MEDICAL EQUIPMENT ��REMIT TO:P.O.Box 9344 N.W.7365 Minnea olis MN 55440-9344 NOV. 9. 2012 11 :51AM HP PATIENT ACCOUNTING 6512651825 N0. 440 P. 2 � '"'"i HealthPartners� :�n� . ' Clinics Mail�top:255068 P0.Box 244 Minneapolis,MN 55440-0244 healthpartners.com 11/09/2012 Babara Solfelt � 3526 timber Ln , Cross Plains, Wl 53528 Dear Babara Solfelt: Account#: 2829398 ' This letter is in resp.onse to your inquiry regarding your accounfi with HealthPartners. Enclosed is itemization for services 06/01/92-19/09/�2 If you have any questions, please contact Pafiient Accounfiing at 651�265-1999 or to11 free at 877-655-2669. Our representatives are available to assist you Monday through Friday, 8 a.m. to 5 p.m_ TTY users call 952-883-5127. Sincerely, HealthPar�ners Patient Accounting 651-265-1999 �, ; . "�,-�.� ,,Go � ~ . �� . , - � � � ,�.ys c �� a O�.r mission is to improve the health of our members,our patients a�ad ttie consmunity 3�76 4' I I I II !�'� ,�;yy 3° . r� �- .t' �♦ :yp' r �g" � iaf�•�s��L� ... � .. ;� � � . NOV, 9. 2012r11___51AMpate]HP PATIENT ACCOUNTING 6512651825 N0, 440 P'P. 3 ofz ,_w...._---..�� _ . , Repore Settings FiQali�Psttnefs Accounr SOLF�LT,BABARA J I2829398] Patient Acco�nY�B Submisslon Information T2x I.D. 41-0797853 8'!7�33rd Av�nue South User. �603312] ��p�s..��t� 55�a��308 �� Time: Fri Nov 9,2012 8:58 AM �QL� [q Transaction IMo�mation �� Servite Date From ServiCe Date To TOtal AmOUnt �uv• p Charges Os101/2012 11/09l2012 2,1o8'�4 D��'l� Tx# Procedure Servite Providef Date AmounS r /�"` 84 La386-WALK BOOT NON-PNEUMATC PREFAB Marstorl.SCOtt B[22668] 06/05/2012 93,00 (Ma�tl�Pmq�� PAY7D�-PM7-INSU�INCE 07H6I2012 74.a0 (Melch Pmt)703 PAY702-PMT.PATIEN7 07/2�0�2 �8.60 r g ►� 85 992140FFICE V1SIT ES7.LEVEL4(9921A�)25M1N Marston,Scott B[22668] 06/05/2012 264-00 (Match Pmt)70D PAY701-PMT-INSU�CE ��Md�� 7�2 (�� (Ma�d�Pmt)103 PAY102.PM7-PATIENT �7/102012 �6,0� (M�trhA�)101 ADJ�1o�COM7RAGTUALALLOWANCE 07neJ2012 6�,88 gg Q4p38-CAST SPL SHRT LEG CAST ADLT FIBRGLS Cole,Peter A(24087J 06/25/2012 220,00 (Ma�M Pmp�04 PAY101-PMT-INSURAr10E 07/23I2012 984.26 (Mdteh Adi)105 P1�J770�CONTRAC7VAL A1L0�1NCE 07i23120�2 55,72 89 99213-OFFICE VISIT EST.LEVEL3(99273)15MIN Cole,Peter A(24U87] 06/25�2�12 177'�� ',Q� (Match Pmt)1o4 PAY101-PMT-INSU�CE 07/��012 719.68 (Malch Pmt)126 PAV7o2-PM1'-PA71E►dT 11N912o'12 15.00 (Ma�UtiAdJ)108 ADJI�O�CON7RACTUAL��OWANCE 07l231'L072 42,92 90 73630-RADEX FOOT COMP�MINIMUM 3 VIEWS 1,NS2 Xr Orillo j35363] 06/25/2012 96.00 (NSalch Pm1)707 PAY101-PM7aNSURANCE �2��2 67'� (�qsl�t,pdg)4oB ADJ7�o-CONTRACTUAL ALLOWANCE 0�23/20'�2 3a.5B 98 73630-RADEX FOOT COMPL MINIMUM 3 VI�WS 3,Hs2 Xr Ortho[35365] 06/25I2012 98•00 (Match Pml)�09 PAY904.PMT-1NSURANCE Q7242012 61.42 �p,�a�chp,cp��1p ADJ11000N7PACTUALA�LOWANCE 072a20t2 �•� 99 99213-OFFICE VISIT EST.LEVEL3(99213)15MIN Cole,PetsrA(24087] 06/OR/2012 177.00 �S, 00 (MatCh Pmt)177 PAY101�PMY-INSU�NCE 07l24/2W2 719.6@ (MBICh Pmt)128 PAY1U2-PM7-PATIE� 17J09/2012 15.00 �vlatchA�)112 ADJ79aCON7RACTUALN-L�WANCE 07/24/2012 4232 102 99213-OFFICE VISIT EST.LEV�L3(99213)15MIN Cole,Peter A[24067] 07/18/2012 177.00 . (Nta�ch Prnc)1'13 7AY701-P�a�URANCE 08/07/j072 �99.68 y�\ (Malth Pml)128 GAY�02��AATIENT 11I0912072 15.OD ��jvCJ (MalcriA��14 AGJ110-CON7RAC7UALAL�OW�ICE 08p7l2012 �.� 115 992'13-OFFICE VISIT HST.LEVEL3(99213)15MIN Cole,Petmr A[24087] 08/20I2012 177,00 (Matcn PmU�20 PAY107.PMT-IN8URANCE ��2 ��9.� (Ma1c.�Vmt)728 PAY104-PAAT-PATIENT 1�p9/�012 15.00 i5�Q� (Mst�h�)t21 AOJt 10-CONIRACTIJ/+�ALLOWANCE 09106M2072 42.32 176 7363aRA�IX FOOT COMPL MINIMUM 3 VIEWS 1,H52 Xr Ortho[35363] 08/20l2012 96.00 (MBldlPmt)124 PAY10t�M7-INSURANCE 04H1lZ()12 87.42 , L . . { � Sv� ��3�� Prof�ssional Billing 1 � 11/9/2012 8:58:28 AM NOV, 9. 2012 11_52AMDate]HP PATIENT ACCOUNTING 6512651825 N0. 440 P'P. 4.o�z .......,� ._..� �'_- - -� � . � - � l�, � �� I (Mgtch AEj)125 AOJ110•CON7RACNAI-ALLOWANCE 09111/20�2 34.59 �`'� 1 118 99214-O�FICE ViSIT ES"f_LEVEL4(99214)25MIN Clark,Claudid F[22101J OB/27/2012 264.00 (Match Pmq�17 PAY9o3-PMT�OS 08l2'7�2012 15.00 ,��Q� (MaErhVmqta2 PAY101-PMT•�NSUI2ANCE 09H�/2��2 187,02 (Malr•h A4j)�23 ADJ110-CONTRACTUAL ALLOWAWCE 09111/20'12 61.96 119 98396-PREVENTIVE VISIT,EST,40-64 Clark,CIBUdia F�22101� 09/05/2Q12 271.00 (Matdi Pmq 126 PAY907-PMT-INSU�+NCE 08252012 2�0.18 (MatchAej)�27 AOJ71o.CON7RE�CTUAIALLOW<.NCE ��a2 �.� Payments Matchedto chargES 1,594.46 AdjustMAnts Metthed to Chdrges 5'I3.54 Note:Tltis report contalns only those payments and adjustments which are matched to the charges listed in the Charges section. � 1 i ' ��°�' �- � 15, oa . �-- � 3 , � ° �� •b � �� Pro£essional Billing 11/9/2012 8:58:28 Al�! .� I « � � � "� �� ,� .. s,, +' '-�'a� .�:. ;% � n _., : � r > � . � E� ,..�� 1 � � �?� .,a , e�nvoice Service Page 1 of 1 ' ��r Regions Hospital ��a';''�` .;•, Payment Approved-Thank You: BABARA J SOLFELT-Payme�t Receipt Friday October 26,2012 04:07 pm ET Account Amount Pay From EPIG2829398 $30.00 Visa***"'*"""'*"5905 BABARA J SOLFELT Ref#: VTJFA13A7873 = Click here to print this receipt Ciick here to � ' � � �O � � � � 0 �S . , https://earchive.ipa�epay.net/regionshospital/ei_CP122 F1_standard.jsp 10/26/2012 �,., .� H �i / 9� ��. � � � . ` .��,�, .;��. - ' - � e' � I +e�:�~ �¢t � - -�,-.. _- _ �'� . . �, yk"I '�r � ��. v a' � , y �� :�°... `++r� � � , � � y + ' M �§ �� +a •;r 4 <��' '�', *� ,�' ;s � , � . x r — - - � �eATIENT ACCOUNT STATEMENT� 30696*TJWOHECAM000211 BABARA J SOLFELT PAGE: 1 of 1 :illi: Region�Hospitalo ACCOUNT NO. STATEMENT DATE HealthPastners Family of Care 2829398 07/17/2012 MAIL STOP 12403A•640 JACKSON ST.•ST.PAUL,MN 55101 AMOUNT NOW DUE PAYMENT DUE DATE $30.00 08/04/2012 Customer Service Phone: 651-254-4791 Thank you for using Regions Hospital's facilities for your services. We expect payment in full now unless you call to make other arrangements. Please see the important information on the reverse side of this statement. DATES PATIENT AND SERVICES PREVIOUS pMTS 8 ADJUST YOUR BALANCE BALANCE Admit Barbara Solfelt 100113830 O6/05/2012 Outpatient Discharge New Charges$1,496.00 O6/05/2012 Previous Balance $0.00 Insurance Pmts/Adj $-1466.00 Personal Pmts/Adj $0.00 Balance Due $30.00 Total Patient Liabiliry $30.00 ' � 30696*TJWOHECAM000211 �� Please detach and return bottom portion with your payment and write your account number on your check.See reverse side for important information. � — ��PATIENT ACCOUNT STATEMENT�� IFPAYINGBYMASTERCARD,DISCOVER,VISAORAMERICANEXPRESS,FILLOUTBELOW. CHECK CARD USING FOR PAYMENT �-�'-� � � M❑ASTERCARD - �COVER R�� V❑ISA A❑MERICAN EXPRESS ilI Ili Regions Hospital CARD NUMBER SIGNATURE CODE EXP.DATE HealthPartners Family of Care SIGNATURE AMOUNTPAID MAIL STOP 12403A•640 JACKSON ST.•ST.PAUL,MN 55101 30696 RETURN SERVICE REQUESTED 282939g 07/17/2012 � .ti.. $30.00 08/04/2012 PAGE: 1 of 1 653546C(PC2) ooso�z oioi �II��I"II��Ii��I�I��J��ul�l�lll��l�l�l�l��nl��l�l'�I �'I�'��I��II��n��l�ll'I�Il��lll�li��l�ll��lt�lil�l� BABARA J SOLFELT REGIONS HOSPITAL APT 107 NW 3969 284 SPRING ST P.O. BOX 1450 SAINT PAUL, MN 55102-4478 MINNEAPOLIS, MN 55485-3969 0000028293980000000030005 �J EXPLANATION OF PATIENT RESPONSIBILITY . Regions Hospital files insurance claims for patients as a courtesy with the understanding that the patient/guarar�tor has full responsibility for payment of the bill. If you are uninsured or under-insured, our Financial Cc�uns�iors will assist you to apply for programs that may be available to help with payment of your bills. Payment is due at this time unless you have made other arrangements with Regions Hospital. However, we would not want the cost to prevent you from receiving the care you need. To discuss payment options or to make payment arrangements within hospital guidelines, please contact our Patient Accounting Customer Service Staff. If you do not make arrangements or if your account is not paid within hospital policy guidelines, it is subject to review for placement with our collection agency or for further legal action. ONLINE BILL PAY IS AVAILABLE FOR OUR PATIENTS VIA OUR WEBSITE: WWW.REGIONSHOSPITAL.COM. UNDER "PATIENTS AND GUESTS," SELECT"FOR PATIENTS," THEN "SERVICES" FOR THE LINK TO ON LINE BILL PAY. OR YOU MAY CALL OUR CUSTOMER SERVICE STAFF AT 651-254-4791 FOR INFORMATION. PERSONAL CHECKS MAY BE PROCESSED ELECTRONICALLY. QUESTIONS ABOUT THIS STATEMENT � Our Customer Service staff will assist you with questions concerning this statement. Our office hours are Monday through Friday 8:OOAM to 4:30PM. Voicemail is available outside regular business hours. For help with billing questions, call (651) 254-4791 or toll free 1-877-974-3600 or email us at regionsbilling@healthpartners.com. Kev pab�xog tej lus nug-nuj nqi, hu rau (651) 254-4791. Hadii aad u baahantahey in lagaa caawiyo su'aalah aad ka qabtid biilka, soo wac (651) 254-4791. Para hacer pregunta,� acerca del estado de su cuenta, Ilame al telefono (651) 254-4791. Neu qujr vi co cau ho' i gi ve van de hoa don, xin goi so (651) 254-4791. You have the option to address any concerns with the Minnesota Attorney General's Office, which can be reached at (651) 296-3353 or 1-800-657-3787. � ASSOCIATED EXPENSES You may receive additional bills from specific physicians who assisted with your care while at Regions Hospital. Please contact them directly if you have questions regarding their bills. The telephone number for the Health Partners Medical Group is (651) 265-1999. �- Thank you for using Regions Hospital facilities for your healthcare needs. Please provide any changes to the information below: Your Name Marital Status Street Address Home Phone City State Zip Employer Business Phone Employer Address Insurance Company Contract No. Insurance Address Insurance Policy No. Other Information OSI Physical Therapy " , � 433 East Mendota Road West S#. Paul , MN 551't 8 . Phone: (651} 552-5928 Fax: {651)450-2211 : . . . , : ,: :. : .' PATIENT;_ACCOUNT-S RECEIPT`. ;. '' , Patient Name: SOLFELT, BARBARA J. Account Number: 1003249 Payment Date: Juf 27, 2012 10:04 AM Receipt Number: 2�12-000012942 Payment Method: Visa Payment Rec'd By: TPiWWolfe . . Appofntrrienf DaEe Time :�.:. :•; . . ;`. :` Payment�ategory , ,:;: `: ; 'Amount , . Friday,Jul 27,2092 09:30 AM Copay $ '15.00 Tuesday,Jul 24,2012 11 30 AM Copay $ 1q.00 .: ,. � , : .; , ;_ , � ; ,, ,;. ._ ;;. ,, ,: ,:.�. Total . �3 ,00 ; _. ,: : � �r . �:.. .._ ..AfiIENT,:A C4UNTS R�GEiPT: . . .... . . .. . r . Patlent Name: S4LFELT, BARBARA J. Account Number: 1043249 Payment Date: Jul 31, 2012 10:25 �AM Receipt Number: 2012-000012955 Payment Method: Visa Payment Rec'd By: TPllsmealey .. _ Appointiiien#:pate.time '" . - -: . � , Paym:ertit C�te9o�'�►'; . �::: � Amoun� Tuesday,Jul 31,2012 14 00 AM Copay � 16.00 :.:..:,,. . _ . . :,:.::- ; - $ 1 •.:.�:;.�:::_ .._, <. , .: � : _ _ .. ..._ _. _.._ . . tal.. . _ � , :: To : . .. : ; ` ' ' 5:00 - . .. ` � : : ;.� : ,-` ;,�PATIENT ACCQUNTS RECEIPT; ;' , . " Patiertt Name: SOLFELT, BARBARA J. Account Number: 1003249 � Payment Date: Aug 02, 2012 10:04 AM Receipt Number: 2012-OOOQ12984 � Payment Method: Visa Payment Rec'd By: TPllsmealey l�pp'oir��mei�t.Datefilme ' >' ;Payment;Cate�ory :; . '� ,..,. . ;• : -Amounf � �'hursday,Aug 02,201210 0�AM Copay , � $ 15.00 =:: . _,.,,.., . , : ; ', - ... ; . , ;. Total :,-� . . , `. :$.'�5:Q0 Please Note:The payment included on this receipt is an astimate of your responsibillly.Payment may be adjusted in the future based on addiGonal information received trom your insurance carrier. PLEASE RETAIN YOtJR RECEIPT FOR TAX PURPOSES Printed:Nov 08,201211:31 AM 7hank you, OSI Physical 7herapy , �� II , ,. � . { � •� � • I , • ,.1� ..� ' , f. ... � �� d!,.�::� � � J ,� Solfelt, Barbara J ( : 2/19/1953 Page 1 of 4 . � � f � � � B�'bara J SOlfelt Description: 59 year old female /��6/5/2012 11:30 AM Office Visit � �� ' Provider: 'Marston, Scott'B i�'' ,�►'�i - '' • epartment:<Rc Orthopedics Dia noses Foot pain - Primary 729.5 "Notes" Marston, Scott B 6/12/2012 6:10 PM Signed CC: left foot pain HPI: Mrs. Sofelt is a 59 yo female who presents to clinic today with left foot pain. She was walking on a"ramp" of sorts yesterday evening, slipped off, and sustained a finristing injury (described as a supination type mechanism). The ramp was approximately 2 inches off the ground. She has been unable to bear weight on the LLE since the accident. She denies other injury. Denies head injury or LOC. Denies n/Uparasthesias. No other acute concerns I 1 Exam: � General: alert/awake, NAD Estimated Body mass index is 24.96 kg/(m^2) as calculated from the following: Height as of this encounter: 5'6.5"(1.689 m). Weight as of this encounter: 157 Ib(71.215 kg). Extremities: LLE -foot -Generalized edema and ecchymosis dorsally and laterally -TTP laterally over calcaneal cuboid joint and over tarsal metatarsal joint between 4/5th MT and cuboid -Pain with gentle eversion of foot. No pain with gentle inversion. -SILT dp/sp/Us/s -Active motion ehl/fhl/ta/gsc -palpable dp/pt pulse Imaging: 3 views of right foot demonstrate bony irregularity of lateral cuboid and lucency in anterior calcaneal process extending into sinus tarsi. There is some malalignment of the 4/5th MT and cuboid joint noted on the oblique films. Lateral xray also demonstrates diastasis between the cuboid and 4th MT base. Assessment: Left foot pain, possible fx vs. Ligamentous injury. Will obtain foot CT for further deliniation of injury pattern. Recommend Cam boot for LLE and NWB LLE in the interim. Pt. Discussed with Dr. Marston and Dr. Solfelt. Definitive management pending. Once the CT has been obtained, will have Dr. Cole review the films as well. David C Ou Yang, MD I was present with Dr. Ou Yang during the history and exam. I discussed the case with Dr. Ou Yang and agree with the findings and plan as documented in the residenYs note. Scott B Marston, MD Previous Version / Solfelt, Barbara J�� Printed by ( 600857) at 11/9/12 3:12 PM . �s� � * ' �•, � . x� � , .� 4 r: - � + r +� ; �'.:4 � � '� � , . ,� _ .. s ; • � . � �� .w ' ,� � Y '�, ,. . . � M � '�, N� y - � t�. z , x f,., ' � ' , � �, +i 4 �.y :f�� :fj1y�� #��•�� { � ,:.��,��flr'b , €' �', ' . � ...� �t �' t �:F� a - y ' .n..�a+�. � . .rv;..,.t X• , 3 q},�,. �� X. �' �O i:;.V� ��,�� 4 ,�,r�,�.,� �'. ,�y:. �� - � . . , �r ''� f '��° �� *kA � '�kh'�� g„i�. . s . . .. �twh'� ��"i � �� -. . 4 ^`t .�`, . :' :! `" �"�' °� �� y '��i . . �� %r: '•� 6 ' .. �� . � � I �,P, k ` i � r �� :.� � �� , - � ro��' � � �`' "�k``. �*` �� I � � ��}��1�` `'...L F� Solfelt, Barbara DOB: 2/19/1953 Page 1 of 4 Bal�barl J SOlfelt Description` 59 year old female 6/6/2012 2:45 PM Office Visit Provider. Cole, Peter A �„ MRN : 01159958 Department: Rc Orthopedics Diagnoses Calcaneus fracture, left - Primary 825.0 "Notes" Cole, Peter A 7/2/2012 2:19 PM Signed The patient is a lovely 59-year-old lady who presents with left-sided foot pain. Two days ago, she allegedly twisted her left foot and ankle in a rut, and fell experiencing sudden left-sided foot pain. She was able to walk on it for a period of time the first day, before having it officially assessed with x-rays and computed tomography scan. That first night, the patient experience worsening pain and swelling primarily in the lateral left foot. She describes no other symptoms related to this accident, no numbness, and symptoms are isolated to the foot. The patient is an otherwise healthy individual, on medications for osteoporosis, and she describes herself as rate active. .� She is a nonsmoker. Physical exam The patient is alert and oriented x3. She is pleasant, normocephalic atraumatic, speech clear. The patient demonstrates gross normal motor function of upper extremities and right lower extremity. Left lower extremity physical exam findings reveal a nontender knee, nontender proximal fibula, Nontender syndesmosis with squeezing of the distal fibula tibia, nontender metatarsal heads and phalanges, Nontender talonavicular and naviculocuneiform joints. Gross appearance of the foot reveals reactive inflammation over the lateral side which is associated with swelling over the lateral aspect of the foot. Skin is in tact. Sensation is intact to light touch over the tibial and peroneal and sural nerve. Flexion extension of toes is strong. Positive findings include acute pain over the cuboid and calcaneus anterior process in the area of maximal swelling. The patient has no tenderness over the base of the fifth metatarsal. No distal fibular tendemess. ' X-ray AP view of the foot reveals a normal aligned medial column with no evidence of fracture or luxation of the talar is navicular middle and medial cuneiform and first metatarsal base. Oblique x-ray of the foot reveals the facets of the fourth and fifth to line up with 1 mm of displacement between the medial base of force and cuboid. The lateral cuneiform cuboid relationship is normal. There is an avulsion fracture at the calcaneocuboid joint and in interruption with less than a millimeter of step-off of the anterior process of the calcaneus at the calcaneocuboid joint. Lateral x-ray reveals a Boehler's angle of 38° of the calcaneus, normal relationship of the anterior process, normal arch and no obvious evidence of fracture. Computed tomography scan left foot reveals anterior nondisplaced calcaneus fracture entering the calcaneocuboid joint and an avulsion fracture at tlhe lateral calcaneocuboid joint of the distal calcaneus. Posterior middle and medial facets and normal relationship with no step-off area no fra�ture of the tuber. No evidence of talar neck fracture. Normal relationship of the loose from and she will heart joints. Assessment plan Nondisplaced anterior calcaneus fracture with no calcaneal cuboid lateral avulsion. Normal alignment the foot. No injury to Lisfranc and Chopart joints. I would recommend nonweightbearing for one month, protected with a cam boot walker, other than well bathing. Ace wrap for comfort. Convert to air cast boot if cam boot is not comfortable. Followup in one month for physical exam and repeat x-rays. Crutch walking with touch down weightbearing only to the left side in the interim. Solfelt, Barbara Printed by ( 600857) at 11/9/12 3:13 PM � �� - . ,• .-,.; � �',. ,� .�� I I � � Solfelt, Barbara� OB: 2/19/1953 Page 2 of 6 SILT sp/dp/sural, saphenous, plantar n. Normal Foot ROM Left P Flexion �5° D Flexion 4p° Inversion �5° Eversion 25 Musculature quad, hams, at, pl, pb,fhl, ehl, edc , fdl firing and normal five/5 xr Showed non displaced anterio facet calcaneous fic. Visible on lat and oblique view. A/P: Barbara J Solfelt is a 59 yr old female superior facet of calcaneus three weeks old all in all doing well Patient is back and seen in follow up with Dr. Cole who advised to return a short-leg cast no weightbearing see her back in two weeks with new x-rays out of the cast. H.SantaAna de la Rosa FMG. OPAC 29-0162 le, Peter A 6/25/2012 5:50 PM Signed The patient is three weeks status post finristing her left foot and ankle at which time she sustained in anterior process of calcaneus and calcaneocuboid avulsion. The patient states that the cam boot is uncomfortable, and moves around too much, giving her fear that she may not heal correctly. She has had a resolving pattern of pain. She is not taking any pain medications at this juncture. She has not tried to walk on it or bear weight. She has been using a rollabout scooter to assist with ambulation. She has no numbness or tingling in her foot, nor has she had any troubles with regard to the skin. Physical exam The patient has a grossly normal appearing left foot. Skin is in tact with no callus, erythema, or focal points of sensory loss or irritation. She is a well-perfused left foot. Sural nerve intact to light touch. X-ray AP lateral and oblique of foot detail the initial anterior process of calcaneus, with approximately 1.5 mm of displacement. More importantly, her foot alignment is within normal limits, looking at the relationship of thek navicula first cuneiforms metatarsal line. She is maintain the arch of her foot. Plan I discussed with the patient the pros and cons of the boot versus a well fitting well molded cast for the next three weeks. I would like to treat her, and continued touchdown weightbearing only, and a short-leg cast to allow a better fitting orthosis. I am recommending a cast just above the mid leg to allow her to continue to use her rol�about. I like to see her in three weeks at which time three views of the foot should be performed. This note was prepared by a Voice Recognition Program. Peter A Cole, MD 6/25/2012, 1:17 PM Scans Type ID Author HPS 301YW72@019NDTBYFOOOF43@1 COLE, PETER A Office Visit Scan on: 6/25/2012 of: NEW PATIENT DME Follow Up Questions Solfelt, Barbara J �rinted by ( 600857) at 11/9/12 3:13 PM A �c, �;�-� , �,s � ��:»- :�-,� .� �„-. . � .,_ .,. t. ��ti„ '��'' ,., ,,,.', i+�i� `•� S •.'��' � .,�t w. Y, '��C � Solfelt, Barbara J DOB: 2/19/1953 Page 1 of 4 B1�al'a J SOlfelt Description: 59 year old female 7/18/2012'8:30'AM Office Visit '' ' Provider. Cole, Peter A MRN : 01159958 Department: Rc Orthopedics Diagnoses Closed fracture of calcaneus - Primary 825.0 Foot fracture, left . _ . 825.20 . otes" Cole, Peter A 7/18/2012 1:15 PM Signed Barb a has returned today approximately 6 weeks status post injuries. She had an anterior process of calcaneus fracture, and a calcaneal plate avulsion. The patient since I last saw her, had opted to have her cast changed, which I understand was perFormed by Dr. Solfelt in my absence. Approximately a week ago, she was using her rollabout when she slipped, and stubbed her ipsilateral great toe. She has had contusion over the area, and opted to have the cast taken off. She comes in today without her cast. Physical exam reveals that she is nontender with deep palpation over the midfoot including Lisfranc and Chopart joints, and specifically over the lateral column. She also had of her toes compressed at the level of the phalanges and metatarsophalangeal joints which are all nontender. She is able to flex and extend her toes. She is contusion over the right great toe tuft, but nail bed unharmed. X-ray Consolidation of the anterior process fracture noted. Good alignment of lateral middle and medial columns of the foot. No evidence of phalanx fracture of the great toe and the metatarsophalangeal joint is located. Plan I encouraged the patient not to use a cast anymore, and she consents. I explained to her that she can use her boot if she wants protection or if it gives her confidence, but I have also encouraged her to wean herself from the boot and from any assistive device. I explained to her that she will not do any harm simply by walking. She may be full weightbearing. I would also like her to have physical therapy two times per week for a month in order to have ankle strengthening and gait training. I believe it will take some time to get her confidence back. I like to see her in 5-6 weeks'time at which time three views of the foot should be performed. In the interim, I explained to her that if her foot became painful or achy at the end of activity or a day, that she is encouraged to take a nonsteroidal medication with her meals, or warm soaks massage etc. This note was prepared by a Voice Recognition Program. Peter A Cole, MD 7/18/2012, 10:02 AM DME Follow Up Questions No data filed Vitals - Last Recorded Ht Wt BMI ` 5' 6.5" (1.689 m) 15 Ib (6.804 kg) 2.38 kg/m2 BMI Data Body Mass Index `fBody Surface Area 2.39 kg/m 2 0.56 m z Allergies as of 7/18/2012 Date Reviewed: 7/18/2012 No Known Allergies No results for this visit Flowsheets - last 72 hours All Flowsheet Templates Encounter Vitals Flowsheet Solfelt, Barbara J �Printed by ( 600857) at 11/9/12 3:13 PM � �� ,,�.., :�: s d N �^,-� W.� ♦ �-. ��A. ,��M � !�•�� .w, - i► � � ` �...�} ,•,v Y,;`..�, ,.. .....(.r.�r. Solfelt, Barbara J �DOB: 2/19/1953 Page 2 of 5 X-�ays were taken today and compared with the opposite on June and they showed a clear healing of the anterior process of the calcaneus with a siide step off. A/P: Barbara J Solfelt is a 59 yr old female status post anterior process of the calcaneus and calcaneal plate avulsion two months and a half already. Doing well anchors encouraged to continue with the physical activities exercising and desensitization to the area. Patient will do back when necessary basis . H.SantaAna de la Rosa FMG. OPAC Scribe for Dr. Cole 651-629-0162' �5 Cole, Peter A 8/20/2012 5:02 PM Signed I had the opportunity to see this young lady, now 2-1/2 months from the time of her initial injury. She states that her left foot continues to be sore, continues to be swollen, has discoloration, and in her words she is just irritated by it. She is walking now without a limp, and would like to begin swimming activities. She has actually been fairly active on the foot, but she confesses to achiness by the end of the day. Physical exam The left foot is slightly swollen relative to the right. She also has some mild redness on the left side relative to the right. She demonstrates good excursion of her toes in flexion and extension, and moves her ankle actively very well. She has no significant heel cord tightness. Her sensation is normal to light touch. She does have mild tenderness with deep palpation over the calcaneal cuboid region, as well as anterior talofibular ligament, and some deep tenderness with aggressive palpation over the tibia the medial malleolus. I am able to massage her foot quite aggressively while distracting her in conversation, and she is not seemingly bothered by this whatsoever. She is able to walk on her tip toes with no limp, demonstrating strong gastrocnemius function and the ability to weight-bear through the midfoot. X-ray Interval healing noted, and she has a completely healed anterior process of calcaneus fracture. She has some mild sclerosis in the cystic change at the calcaneal cuboid corresponding with the area where we feel she had a ligamentous avulsion. Plan I reassured the patient that she is actually doing exceptionally well. I actually feel that she is healing faster than most people who have sustained a fracture and capsular avulsion. It actually remarkable to me that she is able to tiptoe around the room with seemingly no pain or limitation. I explained to her that the swelling will be a symmetric possibly a finro months after such an injury. I explained to her that tearing the capsule and breaking of bone and part a lot of energy to the soft tissues, and it is very common for such injuries to take months to get back to normal. Because swelling represents the volume of blood in the vessels, by definition there will be discoloration and so this is nothing for her to be concerned about. I also asked her if she was better than she was a few weeks ago, and she said " O. Absolutely." I counseled her to continue asking this particular question, "am I better than I was a few weeks ago?" And this will give her better perspective over time as opposed to focusing on whether she has swelling or achiness on a particular day. We did broach the issue a pain syndrome, but I would not say that she has this now. That being stated, I emphasized to her that she should try to desensitize the area by massaging it, using it, perhaps alternating hot and cold just to get her foot used to stimuli. She may followup on a when necessary basis, as I explained to her that I would not do anything different, and I fully expect her to resolve her symptoms in the weeks to come. She certainly knows that she can call back if there any questions. This note was prepared by a Voice Recognition Program. Peter A Cole, MD 8/20/2012, 3:31 PM Solfelt, Barbara J rinted by ( 600857) at 11/9/12 3:13 PM l( •�!'YY� tY �� '�� A � •. � � } °� f '`1� � �� f'�Ah r l', �� } �.�.r.. � .:�e, � Solfelt, Barbara J ( DOB: 2/19/1953 Page 1 of 3 Ba�'bara .l SOlfelt Description: 59year oid female 9/5/2012 1:20 PM Office Visit Provider: Ciark,Claudia F Department Wy Internal Medicine ' Dia noses . V76.10 V76.2 V77..1 _ . V77.91 Vitals - Last Recorded BP Puise : Ht Wt BMI 87/59 85 5'6" (1.676 m) 148 Ib 6.4 oz(67.314 kg) 23.95 kg/m2 Vitals History Recorded BMI Data Body Mass Index Body Surface Area 23.96 kg/m 2 1.77 m z "Notes" � Clark, Claudia F 9/6/2012 8:11 AM Signed ; S Barbara J Solfelt is a 59 yr old female in for routine health maintenance. Current concerns: Doing well on the amitriptyline. Sleeping better and foot pain is better. Present dietary habits: three meals a day and adequate fruit and vegetables , Calcium intake: Adequate=5 or more servings of calcium+vitamin D daily Present exercise habits: at least 30 minutes, 3-5 times a week or equivalent i I have reviewed the family, medical, social and surgical histories. I have reviewed the current medication list. Over the past few weeks, have you felt down or depressed?Yes, due to foot. See appt notes from last week. Do you need assistance with any activities of daily living? no Is your home equipped with appropriate safety features such as smoke alarms, hand rails, adequate lighting? yes Solfelt, Barbara rinted by ( 600857) at 11/9/12 3:15 PM �� "s�,�: � . . `�� J ,� .�.,. .FF�, �4 � �� a * . � a Y�.'�. F.4 Y ..,y, ��I� i' . "i,4' '� ` t�i'+,�st4el�` � • � s=. � u.� 5 yt 4�'y X.�. �d��:: ,1�� S ,,t�. ;,�� s; �4 a.'�,� , .•�.�4 . .� � �.��' . .. . .+�`. 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