Medical Log
Med

Employee Number #11324862


Foundation Medical Sector - Staff Personnel File

Last __Ingram__ First __Johnathon__
Address __██_████████__ City __███████__
Province __███████__ Postal Code __██████__
Birth Date 13/7/1994

Current Symptoms
__ Fever, Cough, Cold-like symptoms
__ Weight Loss
__ Wheezing/SOB
__ Night Sweats
__ Body Misconfiguration
__ Limb Desynchronization
✓_ Changes in Appearance
__ Loss of Primary Sense
✓_ Suspected Pickup of Anomalous Trait
__ Other

Weight 67kg Height 1.7m BP 114/72
Temp 36°c LBM 78

Tests:
Blood AB+

Allergies:
None Currently known

Reported Side Effects

__ Loss of Appetite
__ Fatigue
__ Nausea / Vomiting
__ Abd. pain
__ Jaundice
__ Dark Urine
__ Rash
__ Fever
__ Ringing in Ears
__ Dizziness
__ Numbness
__ Tingling of extremities
__ Joint pains
__ Vision/Hearing Change
__ Behavioural Changes
__ Other
✓_ None

Initial Chest X-ray Date Sep 17th, 2019
___ Negative ___ Abdominal ___ Cavitary
Describe:



Current Chest X-ray Date Sep 18th, 2019
___ Negative __ Abdominal __ Cavitary
Describe:
Treatment
Drug Dosage Frequency Start Date Stop Date
Additional Comments
Next Medical Assessment: N/A
Next Medical Administration: N/A


Date September 18th, 2019
Clinician Assessment/ Progress Notes
Patient Refused Care
Clinician Orders
Patient is to take a 2 week leave from work and must report any anomalous traits or changes to Medical staff and authorized personnel. Should anomalous traits stop during this time, Patient may return to work. Should anomalous traits continue, patient must cease work on this anomaly and must be reassigned.

Refusal Of Medical Treatment

Date: September 18th 2019
Employee Name: Johnathon Ingram
Injury: Suspected 'Pickup' of anomalous traits




I have been advised of the procedures for seeking medical treatment for my alleged work-related injury/illness. By signing below, I am choosing to refuse medical treatment for the above referenced injury. I understand that my signature indicates my refusal of the medical treatment that has been offered to me and that I am completely responsible for seeking medical attention on my own and will pay for any subsequent bills associated with this medical treatment. I further understand that my signature on this refusal form may result in loss of benefits under the NC Workers' Compensation Act.




Employee Signature: Dr. Johnathon Ingram Date: September 18th, 2019

Supervisor Signature: Kevin Hershel Date: September 18th, 2019


WCA Signature Lisa Shaw Date: September 18th, 2019