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Home My WebLink About95-04287 . c1. <.t; . f ( d -; ~ ~ - u f L.. ~ J r I ~ I :r Law Offices JAMES D. FAMIGLlO, ESQUIRE, P,C. Sproul Road at Williamsburg Drive Broomall, PA 19008 (6101359-9220 By: James D. Famlgllo, Esquire Attorney 1.0. No,: 51101 CARLA CLARK 128 E, 22nd Street Chester, PA 19013 v, , Attorney for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA TRIAL DIVISION TERM. NO, tJ..4 - /Id~' .') (~~~J" CIVIL ACTION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS 2520 Lisburn Road Camp Hili, PA 17001 and STATE CORRECTIONAL INSTITUTION AT MUNCY P.O, Box 180 Muncy, PA 17756 NOTICE TO PLEAD You have been sued In Court. If you wish to defend against the claims set forth In the following pages. you must take action within twenty (20) days after this Complaint and Notice are served. by entering a written appoarance. personally or by attorney, and iIIlng In writing with the Court your defenses or objections to the claims set forth against you. You are warned that, if you fall to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice, for any money claimed In the Complaint or for any other claim or relief requested by the plalntiff(s). You may lose money or property or other rights important to you. AVISO Le han demandado a usted en la corte. Si usted qulere defenderse do eslas de estas demandas expuestas en las paglnas sigulentes, usted dene veinte (201 dlas de plaza al partir de la fecha de la demanda y la notlflcacion, Hace fahe asentar una comparencia escrita 0 en persona 0 con un abogado y entregar a la corte en forma escrlta sus defenses 0 sus objeclones alas demand as en contra de su persona. See avisado que si usted no se deflenda, la corte tomara medidas y puede contlnuar la domanda en contra suya sin prevlo avlso 0 notlficaclon. Ademes, la corte puede decldir a favor del demandante y requlere que usted compta con todes les provisions de esta demanda. ~. " YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, PHILADELPHIA BAR ASSOCIATION LAWYER REFERRAL AND INFORMATION SERVICE One Reading Center Philadelphia, Pennsylvania 19107 Telephone: 610-238-1701 Usted puede perder dlnero 0 sus propledades u otros derechos Importantes para usted, LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE, SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA A VERIGUAR DON DE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. ASOCIACION DE L1CENCIADOS DE FILADELFIA SERVICIO DE REFERENCIA E INFORMACION LEGAL One Reding Center Flladelfla, Pennsylvania 19107 Telefona: 610-238-1701 . Law Offices JAMES 0, FAMIGLIO, ESQUIRE, P.C, Sproul Road at Williamsburg Drive Broomall, PA 19008 (610) 359-9220 By: James 0, Famlgllo, Esquire Attorney 1.0, No.: 51101 Attorney for Defendant CARLA CLARK 128 E, 22nd Street Chester, PA 19013 COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA TRIAL DIVISION v. TERM, COMMONWEALTH OF PENNSYLVANIA NO, DEPARTMENT OF CORRECTIONS CIVIL ACTION 2520 L1sburn Road Camp Hili. PA 17001 and STATE CORRECTIONAL INSTITUTION AT MUNCY P.O. Box 180 Muncy. PA 17756 COMPLAINT 1. Plaintiff Carla Clark is an adult individual and citizen and resident of the Commonwealth of Pennsylvania residing at 128 East 22nd Street. Chester, Delaware County. Pennsylvania 19013, 2. The defendant, Commonwealth of Pennsylvania, Department of Corrections is a duly authorized Commonwealth party with Its principal office and/or offices for service of process located at 2520 L1sburn Road, Camp Hili, Cumberland County, Pennsylvania 17001. 3, The defendant, State Correctional Institution at Muncy is located at RD 3, Route 405. Muncy Lycoming County, Pennsylvania 17756-0180 with an address for service of P.O. Box 180, Muncy Lycoming County, Pennsylvania 17756-0180, 4, On or about August 16. 1993, at approximately 1 :30 p,m" plaintiff Carla Clark was lawfully upon the premises commonly known as the State Correctional Institution at Muncy, (hereinafter referred to as "Muncy Prison"), At the aforesaid location, she was lawfully In the shower area, wnen she was caused to slip and fall as a result of an obstruction, defect. or other Irregularity causing the plaintiff to sustain serious and permanent personal Injuries hereinafter more fully set forth. 5. At all time hereto and for a long time prior thereto, said "shower area" was owned by and/or within the possession and/or control of the defendant Commonwealth of Pennsylvania Department of Corrections who was then and there responsible for the care and maintenance thereof, 6, In the alternative, at the times aforesaid and for a long time prior thereto, said shower area was owned by and/or was In the possession and/or within the control of the defendant Muncy Prison who was then and there responsible for the care and maintenance thereof. 7. The negligence and carelessness of the defendants consisted Inter-alia of the following: a. failure to maintain the shower area In a safe manner for those lawfully In that area, Specifically: I. failure to properly maintain the drainage system in the shower area resulting In a backed-up drainage system which caused flooding; II, failure to properly clean and maintain the shower area and. In particular. failure to remove baby 011. skin products and other materials from 2 the floor In the shower area; iii. failure to place safety grips on tha shower floor; lv, fallura to maintain and/or replace worn out and/or damagad safety grips on the shower floor; b, failure to repair the aforesaid obstructions, defects or other dangerous conditions and irregularities; c. failure to warn the plaintiff of the aforesaid dangerous conditions of which the defendant knew or could and should have known in time to remedy same; d. In permitting the obstructions, defects or other dangerous conditions to be and remain in the shower area when the defendant knew or in the exercise of reasonable care should have known of the danger Involved; e, In failing to remove, cover, blockade, or otherwise remove the obstructions, defects or other dangerous conditions of which the defendant knew or In the exercise of reasonable care should have known; f, In permitting persons. and the plaintiff, Carla Clark, in particular. to traverse the shower area when the defendant knew or in the exercise of reasonable care should have known that It was dangerous to do so and Involved an unreasonable risk of harm to persons so doing; g, in falling to inspect the shower area to discover the obstructions, defects or other dangerous conditions or in inspecting so carelessly as not to have discovered these conditions; h, In maintaining the shower area in an Improper manner or In employing personnel who were not sufficiently qualified to maintain the shower 3 area In a proper manner; I, In Inspecting the shower area In an Improper manner or In employing personnel who were not sufficiently qualified to Inspect the shower area In a proper manner; j, In failing to hire, employ or retain personnel sufficiently qualified to supervise maintenance of the shower area; k, In failing to exercise that degree of care and regard for the rights and safety of the plaintiff. Carla Clark, as was required under the circumstances; and I, In being otherwise careless, reckless and negligent as may be ascertained by discovery, 8. As the direct and proximate result of the negligence of the defendants as aforesaid, plaintiff Carla Clark. sustained the following Injuries, all of which are or may be permanent in nature: severe injuries In and about her body, serious Impairment of bodily functions and/or permanent serious disfigurement. she suffered bruises, contusions and a tearing and stretching to various muscles. ligaments. tendons, vascular, nerve and other soft tissues in and about the area of his head, face, neck, shoulders. back. arms. legs, ankles and feet; she sustained multiple herniated disks; she suffered a cerebral concussion with post concussion syndrome; she suffered injury to various bony structures of her body. especially in the area of her head. neck, shoulders, back, arms, legs. ankles and feet and the herniation of multiple vertebral discs; and If, at the time of the accident. the plaintiff, Carla Clark, was suffering from any pre-existing condition or aliment, such were asymptomatic; and, as a result of the trauma, such condition or aliment was 4 activated, aggravated, exacerbated and mada symptomatic she suffered a sevare shock to her nerves and nervous system; all of which did and may and probably will In the future. continue to, cause her great physical pain and mental anguish; and these Injuries may and probably will be permanent In effect. 9. Said plaintiff has In the past and probably will In the future suffer great pain. suffarlng, Inconvenience, embarrassment, mental anguish. and loss of the enjoyment of life: all of which probably are of a serious and permanent nature with permanent disabilities and loss of function, 10. Said plaintiff has expended and will be required to expend large sums of money for medical and surgical attention, hospitalization, medical supplies, surgical appliances, medicines. and attendant services in an effort to have herself treated for the aforesaid Injuries. 11. Said plaintiff's earning capacity has been reduced and permanently Impaired: 12, Plaintiff has been In the past and may and probably will In the future be hindered from engaging In her usual and daily duties, occupations, pleasures and activities. WHEREFORE, plaintiffs claim compensatory and punitive damages from the defendants Individually and Jointly in an amount not In excess of Fifty Thousand Dollars ($50,000.001 plus attorney's fees and costs. Law Offices JAMES D. FAMI I, ESQUIRE, P,C. By: , ~MIGLlO, ESQUIRE for Plaintiff 5 - .. ""---- . ~ v. t.LtJo.. CARLA CLARK (LJa.JL VERIFICATION I, Carla Clark, verify that I am the plaintiff In the within matter and thet the statements made In the foregoing Complaint, are true and correct to the best of my knowledge, Information end belief, I understand that false statements herein are made subject to the penalties of 18 Pa, C.S.A. ~4904 relating to unsworn falsification to authorities, Dated: r-' r ~ ~ ril~ o-Cll1< 11< . Z>< OE-< ~E5 15 00 H UU E-< U ~C ~ OZ ~ o-Cl fa~ .~ ::IrilOH 8~zU ::I rilU :z: E-<~ o Z 'k ~ ~ l.l ~. -l ~ 'K~ ~. '.'\'S~\ ...:) . " ....; ...< i::1 \" " .... -, , f'-J , y) "'-J -. '-.J :::,..,; ~\.. l I,., ;.: II: ~ o-Cl U ~ iil ~ U E-< 11< ril C Ul ~Z 11<0 H ~E-< OU 'tl . ril l:: :> :Z:II: ill E-<II: o-ClO ~U ril ~~ ZO o ~ o U .' .'-J .* \.n '0 -"'" "\ ..~, ~~ r, '" ) " I, >< o-ClU ~Z Z::I 0:;: H E-<E-< U~ ril II:Z 11:0 OH UE-< ::I rilE-< E-<H ~E-< E-<Ul UlZ H ~ o i5~ ::l 2!l.... 8 ]i'e ~ .. ~~ 6 <ti=~ ::: IJ. ",.- c: , In . i! 3: c: '" .. O~;;~~o (1):::"0-: - ~ -.: 8- ~ II:E < :;~ - e", c.. <1l E-< Z H ~ o-Cl 11< :;: o U IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CARLA CLARK, CIVIL ACTION - LAW Plaintiff V. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY NO. 95 -4287 JURY TRIAL DE~mNDED NOTICE TO PLEAD TO ALL PARTIES: YOU ARE HEREBY REQUIRED to respond to the within New Matter within twenty (20) days of the date of service hereof or a default judgment may be entered against you. Respectfully submitted, THOMAS W. CORBETT, JR. ATTORNEY GENERAL \;~ ' tark ttorney General y I.D. No. 51786 Office of Attorney General Torts Litigation Section 15th Fl.. Strawberry Sq. Harrisburg, PA 17120 (717) 783-1683 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CARLA CLARK, CIVIL ACTION - LAW Plaintiff V. NO. 95-4287 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY JURY TRIAL DEMANDED ANSWER AND NEW MATTER TO PLAINTIFF'S COMPLAINT AND NOW comes Defendant. Commonwealth of Pennsylvania, Department of Corrections and State Correctional Institution at Muncy, by and through the Office of Attorney General, and files the following Answer and New Matter to Plaintiff's Complaint: 1. Admitted in part. It is admitted that Plaintiff Carla Clark is an adult. After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of the remaining averments. 2. Admitted. 3. Admitted. 4. Denied. It is specifically denied that the Commonwealth Defendant was negligent in any manner with respect to Plaintiff's alleged cause of action. It is specifically denied an obstruction, defect or irregularity existed or caused plaintiff's alleged injuries. After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of the remaining averments. 5. Admitted only that the alleged injury situs is a state- designated area, ancA that the Commonwealth party has those legal duties as prescribed by applicable state law and regulation. To the extent the remaining averments require an answer, they are specifically denied. 6, Admitted only that the alleged injury situs is a state- designated area. and that the Commonwealth party has those legal duties as prescribed by applicable state law and regulation. To the extent the remaining averments require an answer, they are specifically denied. 7, Denied. It is specifically denied that the Commonwealth Defendant was negligent and careless in any manner with respect to Plaintiff's alleged cause of action. By way of further answer, it is specifically denied that the Commonwealth Defendant was negligent and careless in the following respects: a. Failure to maintain the shower area in a safe manner for those lawfully in that area; i. failure to properly maintain the drainage system in the shower area resulting in a backed-up drainage system which caused flooding; ii. failure to properly clean and maintain the shower area and. in particular. failure to remove baby oil. skin products and other materials from the floor in the shower area; iii. failure to place safety grips on the ohower floor; iv. failure to maintain and/or replace worn out and/or damaged safety grips on the shower floor; b. Failure to repair the aforesaid obstructions, defects or other dangerous conditions and irregularities; c. Failure to warn the plaintiff of the aforesaid dangerous conditions of which the defendant knew or could and should have known in time to remedy same; d. In permitting the obstructions and defects to be and remain in the shower area when the defendant knew or in the exercise of reasonable care should have known of the danger involved; e. In failing to remove. cover. blockade, or otherwise remove the obstructions and defects of which the defendant knew or in the exercise of reasonable care should have known; f, In permitting persons. and the plaintiff. Carla Clark, in particular, to traverse the shower area when the defendant knew or in the exercise of reasonable care should have known that it was dangerous to do so and involved an unreasonable risk of harm to persons doing so. g. In failing to inspect the shower area to discover the obstructions and defects or in inspecting so carelessly as not to have discovered these conditions; h. In maintaining the shower area in an improper manner or in employing personnel who were not sufficiently qualified to maintain the shower area in a proper manner; It is specifically denied that a dangerous condition existed. Per Stipulation of Counsel filed with this Court subparagraphs 7(i), (j), (k) and (1) have been stricken and deleted. 8. Denied. It is specifically denied that the Commonwealth Defendant was negligent in any manner with respect to Plaintiff's ( alleged cause of action or that as a direct and proximate result of such alleged negligence Carla Clark suffered injuries, After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of the remaining averments. 9. Denied. After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of these averments. 10. Denied. After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of these averments. 11. Denied. After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of these averments. 12. Denied. After reasonable investigation, the Commonwealth Defendant is without sufficient knowledge or information to form a belief as to the truth of these averments. WHEREFORE, the Commonwealth of Pennsylvania, Department of Corrections and State Correctional Institution at Muncy, respectfully requests that judgment be entered in its favor and against all other parties. NEW MATTER 13. The present action is controlled by the provisions of 1 Pa. C.S. ~2310 and Act No. 1980-142, set forth in 42 Pa. C.S. ~~8501, et seq., which Acts are incorporated herein and pled by reference. The Commonwealth Defendant asserts all the defenses contained therein. 14. The Commonwealth party is immune from suit pursuant to I Pa. C.S. ~2310, and this action is not within any of the exceptions to immunity as set forth in 42 Pa. C. S. ~8522, and therefore this action is barred. 15. There is no cause of action based upon a failure to inspect or improper inspection in that sovereign immunity has not been waived for such claims. 16. The causal negligence of the Plaintiff is greater than any negligence on the part of the Commonwealth Defendant, and therefore Plaintiff's recovery is barred pursuant to 42 Pa. C.S. ~7102; in the alternative, any recovery must be diminished in accordance with the Pennsylvania Comparative Negligence Act, 17. The Plaintiff was contributorily negligent and/or failed to mitigate the claimed damages, thereby limiting and/or barring any recovery. 18. If the accident occurred as alleged, then the condition complained of did not cause the accident or the injuries complained of. 19. Plaintiff knowingly and consciously assumed the risk leading to her injuries and is therefore barred from recovery. 20. The Commonwealth Defendant did not have notice. written or otherwise, of the allegedly dangerous condition, or in the alternative, if said notice was received. it was not received in sufficient time prior to the alleged accident for the Commonwealth Defendant to have corrected or to have warned the traveling public of the allegedly dangerous condition. 21. The Commonwealth party is immune from suit pursuant to 1 Pa, C.S. ~2310, and this action is not within any of the exceptions to immunity as set forth in 42 Pa. C.S. ~8522, and therefore this action is barred. 22. Should liability be found on the part of the Commonwealth Defendant. the amounts and types of damages recoverable in the present action are limited and controlled by 42 Pa, C,S, ~8528. 23. punitive damages are not recoverable against the Commonwealth Defendant, 24. The Judicial Code at 42 Pa, C.S. ~5522(a), which section is incorporated herein and pled by reference, provides that the Commonwealth and the Attorney General must have received written notice of intent to sue within six (6) months from the date the cause of action accrues. In the absence of such notice. this action is barred. 25. Plaintiff's injuries, as alleged, were caused by other persons or parties which were contributory and/or intervening, superseding causes of Plaintiff's alleged injuries, 26. The Commonwealth Defendant avers that if negligence is found to exist on its part, said negligence was not the proximate cause of Plaintiff's injuries. 27. The Commonwealth party is absolved from liability because any negligence alleged on its part merely facilitated the Plaintiff/s injuries. 28. If the accident occurred as alleged, then the condition complained of did not create a reasonably foreseeable risk of the accident or the injuries complained of. 29. The Commonwealth Defendant is specifically entitled to the defenses see forth in 42 Pa. C.S.A. ~8524, which section is incorporated herein and pled by reference. 30. The Commonwealth Defendant is immune from claims grounded upon negligent supervision or employment. WHEREFORE, Commonwealth of Pennsylvania. Department of Corrections and State Correctional Institution at Muncy, respectfully requests that judgment be entered in its favor and against all other parties. Respectfully submitted. THOMAS W. CORBETT. JR. ATTORNEY GENERAL r; , ~. Stark t Attorney General torney I.D. No. 51786 Office of Attorney General Torts Litigation Section 15th Fl., Strawberry Sq. Harrisburg. PA 17120 (717) 783-1683 VERIFICATION I, Jay W. Stark, Deputy Attorney General. in my capacity as counsel for Defendant in the within action, hereby verify that the foregoing statements are true and correct to the best of my knowledge, information and belief. / Dated: II-({; - 95" S ark torney General CERTIFICATE OF SERVICE I hereby certify that I am this day serving the foregoing document(s) upon the person(s) and in the manner indicated below: SERVICE BY FIRST CLASS MAIL POSTAGE PREPAID ADDRESSED AS FOLLOWS: James 0, Famiglio, Esquire Sproul Road at Williamsburg Drive Broomall, PA 19008 THOMAS W, CORBETT, JR. Attorney Gener,al '.') \ ~ Office of Attorney General Torts Litigation Section 15th Floor. Strawberry Square Harrisburg, PA 17120 717-783-1683 DATED: // -/.p -95- --. IN TIlE COURT OF COIIMON PLiiAS OF Ct,1IBERUND COUNTY, PENNSYLVANIA CARLA CLARK NO, 4287 1995 CIVIL v. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY RULE 1312-1. in the following The Petiti~n for Appointment of Arbitrators shall be subst3nt~ally forn: PETI7!ON FOR APPOIlITIIENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: JAMES D. FAMIGLIO, ESQUIRE. counsel for the plaintifO>>lilWHWlK in the above action (or actions), respectfully represents that: 1. The abolle-captioned action~~Kj;) is ~ at issue. 2. The claim of the plaintiff in the action is $ not in excess of. $20,000 The counterclaic of the defendant in the action is n/a The following attorneys are ~nterested in the case(s) as counselor i1re other- wise disqualified to sit as arbitrators: n/a WHEREFORE, your ?etit~oner prays your arbitrators to whom the case shall be Honorable Court to appoint suooitted. Res~'ectfullY '\ th:'ee (3) ---,- ORDER OF COURT JAM,E~ D. FAHIGLIO, ESQUIRE AND NOW.-8 Pil, '/ _ /4 I 19i1, in consideration of the forego1:lg petition, E"dLNRt2-t:I Cu,'dtJ Esq., ~'f)' &~,"^nEhtAJa/ /i /'l..1/ " .J Esq., and ~7~J1//t. ( J,1Jt..,:fdFl,Esq., are appointed arbitrators in the above-captioned action (or actions) as prayed for. P. J. FLrl)-0:~:E r" -. ,., . ~'.' ~-,....,' I.".' - ',,\i "1 ,." I' ,. I" I I , I' I' . ..~ j',,; l' ,. c..:...,' ; I h.Ni.:;jl~\"\:\'" -:;:- -,.. <:::t ; '. CI ;;q ,) 0- , " 0- Q 1I( .. ..-. . Il () . ~ f;~ '. .', Q -' 0 c' 0 L L_ ~ ~ " ~- ~ "* I" ~ rl.. ~ . . CARLA CLARK, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. No. 95-4287 Civil Term COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTE AT MUNCY, Defendant CIVIL ACTION - LAW NOTICE OF HEARING BY BOARD OF ARBITRATORS You are hereby notified that the Board of Arbitrators appointed by the Court in the above-captioned case will sit for the purpose of their appointment in the Second Floor Hearing Room of the Old Courthouse, at Carlisle. Pennsylvania, on Thursday, November 20, 1997 at 9:00 a.m. Keith O. Brenneman, Esquire Stephanie E. C rtok. Esquire Dated: / /)(3/17 By: Edward E. Guido, Esquire Chairman, Board of Arbitrators James D. Famiglio, Esquire Sproul Road at Williamsburg Drive Broomall, PA 19008 SAID IS, GUIDO, SHUFF & MASLAND 26 W, Hlsh Slrecl C..U,le.PA Jay Stark. Esquire Deputy Attorney General Torts Litigation Section 15th Floor Strawberry Square Harrisburg, PA 17120 SHERIFF'S RETURN - REGULAR CASE NO: 1995-04287 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND CLARK CARLA VS, PA COMMONWEALTH OF ET AL LEROY HIPPENSTEEL , Sh&riff or D&puty Sheriff of CUMBERLAND County. P&nnsylvania, who b&ing duly sworn according to law. says, th& within COMPLAINT upon PENNSYLVANIA COMMONWEALTH OF d&fendant, at 1015:00 HOURS, on th& ~ day of S&pt&mb&r was s&rv&d 1995 at DEPARTMENT OF CORRECTIONS CAMP HILL. PA 17001 County, P&nnsylvan1a, by handing to TRACEY MCCULLOUGH CLERK TYPIST a tru& and att&sted copy of th& COMPLAINT and at th& sam& tim& dir&cting tl2L att&ntion to th& contents thereof. Sh&riff's Costs: Docketing Service Affidavi t Surcharge 18. 00 So answ&rs:~' . ...,,-:---:: 8 ....--..,...,., ~~.. ..." '.~"......:...':. . 40 'f'"' ' ,~.". :" ,00 2.00 R. Ihomaa Kllne, ~her111 628.40 'JAMES D.FAMIGLIO .H .>" 09/11/1995 j ~ ?, '1u by k . ~ ~ erlff Sworn and subscribed ~o before me this Jlw day of ~.......i____ 9 ., I, " ~ A. D. '--h" ~ ~'D. _ ..ML rot onotar"y=f=1 the SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 1995-04287 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND CLARK CARLA VS. PA COMMONWEALTH OF ET AL R. Thomas Kline , Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named defendant, to wit: ATTORNEY GENERAL'S OFFICE but was unable to locate Them in his bailiwick. He therefore County, Pennsylvania. deputized the sheriff of DAUPHIN to serve the within COMPLAINT On September 11th. 1995 this office was in receipt of the attached return from DAUPHIN County, Pennsylvania. Sheriff's Costs: Docketing Out of County Surcharge DAUPHIN COUNTY So answers: 6.00 9.00 2.00 22.50 639.00 JAMES D. FAMIGLIO 09/11/1995 R. Thomas K11ne, ~ner1~~ Sworn and sUb6cribedlo before me this JI..t day of _I>l~-1..- . 19 9'; A, D. Ch1~ ~. )h<l'u~ ~. rothonotiir COMMONIH;AI:l'll OF I'liNNA: COUNTY 01' DAlJl'llIN: SlllilUFF'S Rli'l'lIHN NO, 95-4287 Civil Term I'ACJIi 456 ,; III 95 ,lit 10:30 A~I. AND NOW: August 17th WITIIIN __ ~P~~.!',t_~~~_ N.ot!,:~ Attorney General S~:RVlm TilE UPON IIANDING '1'0 Stacy Wict, Clerk III, and person in charge at time of IIY PERSONALLY service A TRUE ATTESTED COPY OF THE ORIGINAl. AND MAKING KNOWN '1'0 her Complaint and notice of business, 16th Fl. strawberry Sq. Harrisburg, Pa. TilE CONTENTS THEREOF AT their place Hworn and SUhSC1' thud t.. before me thi518th (~or august II) ..~~Jw~, f (}tt;A7I')) I 11'1l0'l'HONO'l'AHY HIA i, i , i i SO ANSWlmS . . ~J?el~ ?{. ~~M.SD SHERIFF OF DAUPHIN COUNTY, PCNNA :an' d~r.<w::;"-..C~ L-Q'.4-? DEPUTY SHERIFF 95 SIIEIUFF'S COST.. .:):;.50 f.... "J"'n' ~_ COUrT' CT" C-mm...."" ::t",_... "'To ,-......- .IW:.......-l ~'"."-..'I P-"'r:"'yl',,,,-,- h. -.. &, ltJt" --~..... "'-,""",..-.;;.. .-,,"- .......,'-~.I~ I ;...... .......1.... Carla Clark 'is, Attorney General's Office ~o. 9'l-4287.. C;v; 1 .Tprm ---. :?- ~OWJ AUQust 14. 1995 :9_ !. S:~..z:~ O? C~GE?..!.A."m COt,"':'{TY, .?~ co h=-.by d...:=u= C: .sn:::..:i ai Dauchin C~u:t'1 :0 =::=.1t: = trY:::, .... ... ., . :.:::s ~-=u=:cn .:~..,,,, -....- ~t == :::::u=t :':C1 . ~ . :':..:k of :.:: ?!:L!:::I. r~~~ 5he..~ :f C;:::er.:u:d c"u:rr. ?:l. .4..Sda:vit or S~:'"7ic= ~OW, ~9 .. o\:!cc:: "t. 1::-.*:':i :.:: ~.~:" '~pal1 ~; by ::u:~ :0 ~ cpy at = ::::-.,1 ... :I.lId _!t':. !=wn :0 :.:: .:::t:::s :..-:===t. So =w=. ~lo"':~ 01 CoWltT. ?~ SWCQ :me! s::i::sc:-J:d bCc:n: ccsrs ::J:..~v"IC::: ~!:IU:.-\G c: .-\: :1.1.>.'1. VIT .s =: :::s _ c!:1y oi 19_ s f_ --.. '..'- . ow_'.'.". ~;,.. _. . ..' ,., SHERIFF'S RETURN - OUT OF COUNTY CASE NOI 1995-04287 P COMMONWEALTH OF PENNSYLVANIA I COUNTY OF CUMBERLAND CLARK CARLA VS. PA COMMONWEALTH OF ET AL R. Thomas Kline , Sheriff, who being duly sworn according and inquiry for the within INSTITUTION to law, says, that he made a diligent search named defendant, to witl STATE CORRECTIONAL AT MUNCY but was unable to locate Them in his bailiwick. He therefore County, Pennsylvania. deputized the sheriff of LYCOMING to serve the within COMPLAINT On September 11th, 1995 . this office was in receipt of the attached return from LYCOMING County, Pennsylvania. Sheriff's CostSI So answ~rsl Docketing Out of County Surcharge LYCOMING COUNTY 6,00 9.00 2,00 27,00 ~ .... -:/ f' / ~? "-. ..._4- R. Ihomas Kline, Sheriff B44,~~ JAMES D. FAMIGLIO 09/11/1995 Sworn and subscribed to before me this day of 19 A. D, I'rothonotary I .r,.. C it C t ......T r",~ .-- ....~.......~ .'.,.........'1 p- '" I ............ n I nel" ou CT .:::mmO=1 r =:-. ~. ..........-,~" .-..... 1..,......."" =:1r:...y '1.....1... Carla Clark State Correctional Y~Btitution at Muncy ~o. 95-4287 Cavil Term ---. :~-- :iow, August 14, 1995 ~9__ !. SEZ:~::' O? C~GE?..!.A..'i!) COt-~TY. ?A... ca =::-...b)' c...::u= = Sb:.E oi Lycoming Cwu:q :0 ::::::-.:.t: :is ',V:::, ... .. . ., d .. .. :::s =u=::cn =~...,fII' -.....- :1t :.::: ::::u::t:.: :-~ Ot :::: . ~ . :n":_::i. .-?'./'J; , ~/~ f ~-..,,~~~ She."'1.:f ::~ C::::::er'..:u:cl C"U:t7. ?~ .4..Sdavit or S~:'"7ic= ~ow, AUGUSR 30TH . A o'dea ~t. l=-.o::i 95 10115 ~9 . -- :.:e wi.:":" COMPLAINT & NOTICE ~paa S.C.I. MUNCY (DEFENDANT) ~; S.C.I. MUNCY, RD3 BOX 405, MUNCY. PA 17756 =r::u:~:o CAPTAIN MUSSER ~ c::py of = =:::-:_-9' COMPLAINT & NOTICE md -~..:- !=wn :0 HIM ... . ,. :.:e .:=::.::::s :'::::=1. So =w=. C.w u ~~ ".J', CHARLES T. BREWER Shc:ii of LYCOMING CoWl'T. ?.. SWCQ :m*i::sc:-J:d ccc:n: . =: ~a Qvat !g!l.Q .~. ccsrs S1:2 V-Ie::: ~!:IU:.-\G c: .-\:: UJA;"IT " ' ~. ,'~'. ~' , , / I;' .. I: ... .._.~ I ~... ':-:-", 18.00 6.50 2,50 ---. ____I WILt'l,'\~ J. r;.~;\ PlotlL ":::,11',: ( . r. "! C1urt1 _W~rll; ell,' ;,1,'. j t",tlly, PJ, My (1.1"" ',',,'j I., I J.:n. I), IY96 ',.s ,27.00 '..cJ> v LAW OffiCES SAIDIS, GUIDO, SHUFF III MASLAND l6W,IIIOH ~T.._ '. ll09MARKETSTRF.ET CARLlSl.B. PA 17013 CAMP HILL. FA 17011 PIIONH (717) l4l,621l PHONE (717)737.3405 SAlOIS, GUIDO, SHUFF & MAS LAND 26 W, Iliah Sir... CllIlisle,PA CARLA CLARK, plaintiff v, COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTE AT MUNCY, Defendant CI!RTIFIBD COPY: ~~ . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No, 95-4287 Civil Term CIVIL ACTION - LAW NOTICE OF HEARING BY BOARD OF ARBITRATORS You are hereby notified that the Board of Arbitrators appointed by the Court in the above-captioned case will sit for the purpose of their appointment in the Second Floor Hearing Room of the Old Courthouse, at Carlisle, Pennsylvania, on August 26, 1997 at 9100 a.m, Dated: '/5"(77 Keith 0, Brenneman, Esquire Stephanie ~ ok, Esquire By: Edward E, Guido, Esquire Chairman, Board of Arbitrators James D. Famiglio, Esquire Sproul Road at Williamsburg Drive Broomall, PA 19008 Jay Stark, Esquire Deputy Attorney General Torts Litigation Section 15th Floor Strawberry Square Harrisburg, PA 17120 ~ Law Offices JAMES 0, FAMIGLIO, ESQUIRE, P.C, Sproul Road at WIlliamsburg Drive Broomall, PA 19008 (6101 359.9220 By: James 0, Famlgllo. Esquire Attorney I,D, No,: 51101 Attorney for Defendant CARLA CLARK, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW Plaintiff v, No. 95-4287 Civil Term COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY, Defendants PLAINTIFF'S ANSWER TO DEFENDANTS' NEW MATTER TO PLAINTIFF'S COMPLAINT AND NOW comes plaintiff, Carla Clark, by and through her attorney. James D. Famiglio, Esquire. and files the following Answer to Defendants' New Matter to Plaintiff's Complaint: 13, Denied The averments in this paragraph constitute conclusions of law to which no responsive pleading is required. 14, Denied, The averments in this paragraph constitute conclusions of law to which no responsive pleading is required, 15. Denied, The averments in this paragraph constitute conclusions of law to which no responsive pleading is required, 16, Denied. The everments In this paragraph constitute conclusions of law to which no responsive pleading Is required, 17, Denied. It Is specifically denied that plaintiff was contributorily negligent and/or failed to mitigate the claimed damages, thereby limiting and/or barring any recovery. The averments In this paragraph constitute conclusions of law to which no responsive pleading Is required. 18, Denied, It Is specifically denied that the condition complained of did not cause the accident or the Injuries complained of, To the contrary, the condition complained of directly caused the accident and/or Injuries complained of, 19, Denied, It Is specifically denied that plaintiff knowingly and consciously assumed the risk leading to her injuries and is therefore barred from recovery, After reasonable Investigation, plaintiff is without knowledge or Information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied. 20. Denied, The averments in this paragraph constitute conclusions of law to which no responsive pleading is required, After reasonable Investigation, plaintiff is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, 21, Denied. The averments In this paragraph constitute conclusions of law to which no responsive pleading Is required, After reasonable Investigation. plaintiff Is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, 22. Denied The averments In this paragraph constitute conclusions of law to which no responsive pleading is required, After reasonable Investigation, plaintiff Is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied. 23, Denied. The averments in this paragraph constitute conclusions of law to which no responsive pleading Is required. After reasonable Investigation, plaintiff Is without knowledge or Information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied. 24. Denied, The averments In this paragraph constitute conclusions of law to which no responsive pleading is required. After reasonable Investigation, plaintiff Is without knowledge or Information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, 25, Denied, The averments In this paragraph constitute conclusions of law to which no responsive pleading is required, After reasonable investigation, plaintiff is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, 26. Denied. It is specifically denied that if negligence is found to exist on the part of the Commonwealth Defendant. said negligence was not the proximate cause of plaintiff's inJuries, To the contrary, said negligence is the direct cause of plaintiff's injuries, 27, Denied, Denied, The averments in this paragraph constitute conclusions of law to which no responsive pleading is required, After reasonable Investigation, plaintiff is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, 28. Denied, The averments In this paragraph constitute conclusions of law to which no responsive pleading Is required, After reasonable Investigation, plaintiff Is without knowledge or Information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, 29, Denied. The averments In this paragraph constitute conclusions of law to which no responsive pleading Is required, After reasonable Investigation, plaintiff is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied. 30, Denied, The averments in this paragraph constitute conclusions of law to which no responsive pleading is required. After reasonable investigation, plaintiff is without knowledge or information sufficient to form a belief as to the truth of the averments of this paragraph and said averments are therefore denied, WHEREFORE, defendant, Carla Clark, demands judgment in her favor and against plaintiffs, without prejudice, together with Interest, costs, attorney's fees and such other relief as deemed to be just and appropriate under the circumstances, Law Offices , JAMES D, FAMIGLlO, ESQUIRE, P.C, By: , ;' .-', , I I ./ \ ._,j :,..... _//1 JAMES D'fAMI~l!fO, ESQUIRE Attorney ,for Plaintiff ~c. VERIFICATION I, JAMES D, FAMIGLlO, ESQUIRE, verify that I am the attorney for the plaintiff, Carla Clark, In the within matter and that the statements made in the within Answer are true and correct to the best of my knowledge, I understand that false statements herein are made subject to the penalties of 18 Pa. C,S,A. 14904 relating to unsworn falsification to authorities, Law Offices JAMES D, FAMIGLlO, ESQUIRE, P,C, - \ \----- , , By: ~......4' JAMES,Q, FAMIGLlO, ESQUIRE Attorney for Plaintiff Dated: I I "'" -,. , - ~-,.. '-I ':. , " CERTIFICATE OF SERVICE I hereby certify that I am this day serving the foregoing Answer upon the persons OInd in the manner Indicated below: Jay W. Stark, Deputy Attorney General Office of Attorney General Torts Litigation Section 15th Floor, Strawberry Square Harrisburg, PA 17120 TYPE OF SERVICE: First Class Mall. Postage Pre.Paid Law Offices ' I JAMES D, FAM!GLlO, ~SQUIRE, P,C. " , l- By: ,r--::.-- ~ \, JAMES D. FAMIGLlO, ESQUIRE Attorney for Plaintiff Sproul Rd, at Williamsburg Dr, Broo'mall, PA 19008 610-359-9220 Dated: I I -," ,-~ -'1' NOTE: Under 18 Pa,C.S. ~4904 (Unsworn Falsification to Authorities) a knowingly false Certificate of Service constitutes a misdemeanor of the second degree, !:? le r-. -'>' ,'-1 ,::"- ~:: :; ~_. - ~': .~2 -)-':; ->::- .~ .~ -- '" ".. -"" -'= 'n"::; -...;.1-.1 . ::' .... ~, .~. .r .. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CARLA CLARK, Plaintiff v. COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY, Defendants CIVIL ACTION - LAW No, 95-4287 Civil Term ENTRY OF APPEARANCE Please enter my appearance on behalf of the Defendants, Commonwealth of Pennsylvania, Department of Corrections, and State Correctional Institution at Muncy, in the above-captioned action. Office of Attorney General Torts Litigation Section 15th Fl., Strawberry Sq. Harrisburg, PA 17120 (717) 783-1683 ">:......~. Respectfully submitted, WALTER W. COHEN ACTING ATTORNEY GENERAL ~ , tark ttorney General 1.D, No. 51786 ;' .... CERTIFICATE OF SERVICE ! hereby certify that I am this day serving the foregoing document(s) upon the person(s) and in the manner indicated below: SERVICE BY FIRST CLASS MAIL POSTAGE PREPAID ADDRESSED AS FOLLOWS: James D, Famiglio, Esquire Sproul Road at Williamsburg Drive Broomall, PA 19008 By: WALTER W. COHEN Acting Attorney General u),2] ark torney General Office of Attorney General Torts Litigation section 15th Floor, Strawberry Square Harrisburg, PA 17120 717-783-1683 DATED: ~':1~-q5 ~ ::r.:: .~ on .... ,- >- .:: ,-- "'\..;." .1 t.I,.,-. :::~? :-:: " - ::-" c:r> "'" ,-. ::> ~"'" '~. ( ..., ... IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CARLA CLARK, CIVIL ACTION - LAW Plaintiff v. No, 95-4287 Civil Term COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY, Defendants STIPULATION OF COUNSEL It is hereby STIPULATED and AGREED by the underoi'.Jn'3d counsel that subparagraphs 7(i), (j), (k) and (l) are hereby stricken and deleted from the Complaint. It is further STIPULATED and AGREED that the words "or other dangerous conditions" found in , deleted subparagraphs 7 (d), (e) and (g) are hereby from the Complaint, Dated: q-t~9(" ja At Dated I &[- b --if!{ Jay Dep A ark torney General for Defendants v. I CIVIL ACTION - LAW I I I I I I I I I NO. 95 - 4287 Civil Term , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNT~, PENNSYLVANIA CARLA CLARK, Plaintiff COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF CORRECTIONS and STATE CORRECTIONAL INSTITUTION AT MUNCY, Defendants BRIEF IN SUPPORT OF MOTION FOR A NONSUIT The Department of Corrections argueo that it is entitled to judgment in its favor for any or all of the following reasons: (l) The Department cannot be held liable for a failure to remove foreign substances from its real property; (2) Plaintiff will not present evidence demonstrating the Commonwealth Defendant had prior notice of a dangerous condition of its real estate; (3) plaintiff will not be offering into evidence the testimony of an expert witness to eatablish that the plaintiff's alleged injuries and aymptomo were the direct and proximate result of a defect of Commonwealth real eatate. Pursuant to 1 Pa,C,S.A. Section 23l0, Defendant PennDOT enjoys , sovereign immunity absent a legislative waiver of that immunity, Liability may be imposed upon a Commonwealth agency only when a plaintiff brings a cause of action that falls within one of the nine exceptions to sovereign immunity. 42 Pa. C.S,A, Section 8522 (b) (1) - (9) . It is well established that these limited exceptions are to be strictly and narrowly construed, First Nat. Bank of Pennsylvania v. Comm., Dept. of Transo, , l48 Pa. Cmwlth. l58, 609 A.2d 9ll (1992), appeal denied 614 A,2d 1144, Bruce v, Comm.. Deot, of Transp"l38 Pa. Cmwlth, l87, 588 A.2d 974 (l99l), Davidow v. Anderson, 83 Pa. Cmwlth. 86, 476 A,2d 998 (1984). The Pennsylvania Supreme Court has held that in order for the real estate exception to apply, the dangerous condition must derive, originate from or have as its source the Commonwealth realty. Snvder v. Harmon, 522 Pa, 424, 562 A.2d 307 (1986); see also Kiley v. City of Philadelohia, 537 Pa. 502, 645 A,2d l84 (1994), An artificial condition or defect of the land itself must cause the injury. Snyder, 522 Pa. at 434-435, 562 A,2d at 3l2. The Plaintiff has not offered any evidence that the alleged slippery condition derived, originated from and had as its source Commonwealth real estate, Plaintiff will not be presenting any evidence which proves that a defect of the real estate itself caused her injuries. Rather, the evidence offered has been only by the plaintiff herself who says simply that the shower area was wet . and slippery. Numerous cases have held that a plaintiff's injuries do not fall within an exception to governmental immunity where foreign substances accumulated upon governmental real estate, Fitchett v. SEPTA, l52 Pa. Cmwlth, l8, 619 A.2d 805 (1992); Walker v. Phila. Housina Auth., l58 Pa, Cmwlth. 497, 63l A.2d lll7 (l992); Deluca v. School Dist, Of Phila, 654 A.2d 29 (l994); Shedrick v, Wm. Penn School dist, et ~, 654 A,2d l63 (1995); Finn v. City of Phila., 541 Pa. 596, 664 A.2d 1342 (l995); Metkus v. pennsburv School Dist., 674 A.2d 355 (1996); Leonard v. Fox Chapel Area School Dist" 674 A,2d 767 (1996); Wolfe v. Stroudsbura Area School Dist" 688 A,2d 1245 (1997). These cases clearly stand for the rule that no waiver of immunity exists where there is no proof of an inherent, defective design of the real estate itself, Without such evidence, the case must be dismissed, Other reasons dictate that a nonsuit should be granted by the Board. The Supreme Court has ruled that notice of a dangerous condition is a prerequisite to maintaining a cause of action. PennDOT v. Patton, 546 Pa. 562, 686 A.2d l302 (1997). Plaintiff has not presented any evidence which shows that the Commonwealth had notice of an alleged dangerous condition of its real estate. The Commonwealth Defendant is also entitled to a nonsuit due to Plaintiff's failure to offer necessary testimony, The testimony of expert witnesses is required when special skills and training are necessary to understand the subject matter or when technical knowledge beyond that possessed by the average juror is required to resolve an ultimate issue, Steele v. Shepperd, 4ll Pa. 481, 192 A.2d 397 (l963), Expert testimony is also necessary when the subject matter is related to some science, profession, business or occupation beyond the average layman, United Penn Bank v. Bolus, 363 Pa. Super. 247, 525 A.2d l215 (l987), appeal denied 518 Pa, 627, 541 A,2d 1138 (l987). The cause of an internal injury such as plaintiff alleges here tills into this category. The testimony of an expert is indispensable in proving that her injuries and symptoms were proximately caused by a fall in the shower area in August 1993. Tennis v. Fedorwicz, 140 Pa, Cmwlth, 7, 592 A,2d l16 (l991), plaintiff will not be presenting any expert medical testimony. She cannot, therefore, possibly recover because she has failed to prove her case as required, Consequently, a nonsuit must be granted. There is no genuine issue as to any material fact. The Department of Corrections is immune for the condition of which plaintiff complains and is entitled to judgment as a matter of law, ,~ Respectfully submitted, 0, MICHAEL FISHER ATTORNEY GENERAL -- & Attorney General No. Sl786 Office of Attorney General Torts Litigation Section lSth Fl., Strawberry Sq, Harrisburg, PA 17120 (717) 783-1683 ,-~- CERTIFICATE OF SERVICE I hereby certify that I am this day serving the foregoing document(s) upon the person(s) and in the manner indicated below: SERVICE BY HAND DELIVERY ADDRESSED AS FOLLOWS: James D, Famiglio, Esquire Sproul Road at Williamsburg Drive Broomall, PA 19008 D. MICHAEL FISHER Attorney General By: I tark Attorney General Office of Attorney General Torts Litigation Section 15th Floor, Strawberry Square Harrisburg, PA 17120 717-783-1683 DATED: /1-,;) D -17 ARB/TAT/ON PACKAGE Carla Clark v. Commonwealth of Pa, Dept. of Corrections and State correctional Institution at Muncy 95-4287 James D. Famiglio, Esquire Sproul Road at Williamsburg Drive Broomall, PA 19008 610-359-9220 MEDICALS \' \ I' ;.: , 1. Muncy Valley Hospital 2. S.C.!. at Muncy - Records 3. Muncy Valley Hospital - P.T. 4. Penn-Del Medical Associates 5. MRI's 6. Dynamic Physical Therapy .. \J ....-...~ \: _ __01 l. . . : ..~~l~~~W;;,'!;#c!.,'7,,'~V,;!;""l:;^j,...;'lf_\('r,.o;o,....'~~\,~1~_"_._~,_._~"...". '" .....-- , o . ,'.' ~ ,-......",.... ,'"...~......""""."'-4U,~,t~..~ ( '\ J!o.-_~~,._...._,.~ "__''+- - , -___.~:<.'i ....- . J~ Muncy valley lIospltal 'willi EMERGENCY ROOM RECORD ':11:~.!'j cop,' . ~~.. MLD llLC NO 'T.A:C1-;;O-- '''rL , 19256194594711a39 _.1.____ COU,il I ll~ ..v,'l 'flC..HQt,t 646-3171 .J. ItO'>>P.t.LflV _I:MR _ - , "J(~'''''''''f I~ASt'llU( WoOO.IIIW'l"" IIfO HlillhMlJ,vkD,lIltlJl.lk_1 RlL BI"'HPLAC;E II SIREU call PO OOK 1801 MUNCV,PA 17756 A ..., H' ",. A 'I'~ DR ADAM'M:'ED~LMAN .. - -.. 'l-IrZ , ./IJ'tUArtl/!. ," . ., . ... '. '1~q.$' !:Sb~ ",,,,, N .;2" OR OFFICE .....-- ...-....... " ..~"..I ...' . . " - l'A RDEHS "'__' . ..., i _~I...:- o cse CI SIREP stREEN OH OPl.PIT o SeA Cl UA PAEG o AMYLASE CJ srRlJU PI"EG o LEVEL OUA CJ UACIS D OTHER OCAAO\4CLoIBS '.' ',X'RA,~Rl!ERS:. ',:' o CHEST 0 KNEE R L ORISSRL 0118.fl8 R L OKUS OANKLt R L o ABO. senll::'s 0 FOOT "L r.J~ULL OSHOU\.DER ~C'SPINE 0 C"'~CLE R L OTSPINE OCLBOW R L LS SPINE CJ'l\'f\lsr R I o PELVIS 0 HAND R L CleAT sr."" \ OTHER PULSE Cl OXIMETER D PCN\ FLOW 07ZJt I. I I I I l ""':.:::-::,;;",;; ~._'-' . - . o 'INITIAL VISIT 0 RE ECK N J:ke ,- AlLERGIES Muncy valley Hospital ER TRIAGE RECORD N~E--DAuL Ovjil ACCOUNT NO, o CONOITION ON ARRIVAL' [J STAO I:JOUAROED I I CRITICAL II OOA n A lATORY r: OUlANCE Il OTHER ARRIVED n CONSCIOUS n S6!I,CONSClOUS n UNCONSCIOUS NOTIFIED 0 CORONER 0 POLICE () RElATIVE ,SPiCIFV T. n ER [1 OOCtOR SKIN w.... 0 lllI' [) CXXll. 0 ..... 0 "'-""', o C'tAHotlC 0 ID(Mol_ ... NURSES SlONA TURE DATE ,_. ,., ... - I CONSENT, AllOW, AND AUTHORIZE MEC'.CAl OR SURGICAL TREATMENT INClUDINO, OUT NOT LIMIT EO TO ANY TF.~T, TRANSFUSIO',s, INJECTIONS, MEDICINES AND ARRANOEMENTS rop ANESTHES'A AS ','.W OE DEEMED NECESSARY III TIlE JlJOOMENT OF THE PHYSICIANS ANOIOn SURGEONS AT NO THE MUNCY VALLEY HOSPITAL SIGNEO WITNESS , - RELAJIONSHIP --"" - ---- NURSE'S NOTES ; I , ! 1 CURRENT MEDS -' ; 1 I , j a I 1 PULSE :. "': ~ ..: .' ", ,. ,. "". '. PAST MEDICAL HISTORY ....:- i;~"".' . , , PIlII: RUO RlO FIonk Ep;guItIc ~~JV~::'l"AOrHl" 0 SlHTi" 0 UHf HOWE 0 H4 co;;;;.OOHOHOtSl'OSlTlONASTADLE 0 GUAIUlal 0 CAlTlCAl. T"'E'OF ~sylON -111 C1I , DlsPosmoo ~ ~ 0 TllANSfERRtD TO 0 EXPIRED J ' 0 AOf.IITTED TO AU. FOR on I.',.. .'.' --',', ,-.-..- ._, I ~ NURSE'S NOTES CARDIOVA C. LAR AND TRAUMA FLOWSHEET o A CARDIOVASCULAR Hhylhm laid Monilot 0 No 0 VI. o -'111m. Pacemlker 0 No 0 Vn Masl 0 No OVe. IV'I o R_ _Sol..lIon o L_ Solution ___ RIIt AIRWAY o Natural o NON! o O<aI 002 BREATHING o Sponlanoou. BREATH SOUNDS R, L o E,T. Tube , o N,T. Tube , o 0Ih0< UM OArtiIldaJ TIME BP TEMP PULSE RESP "',' ," .:~,; / .. .., .., . ,. ..' llWIIWl COOES A. A8AA8lON ' lo8UAH O,lXlHTUSlOH D. DECUIITIIS E. ECOf\'II08OS L. LAlVlATIOH P . PIJHI:TUAE R'RA8H S.IWEUfjQ , . 1..... . .......- . . '.__n. ':'. .-, __ " '::1: .'" ~.:. " ~ ,~~..:. ,". I . ~:. ". ~ . '" .J.. ", .: '.':" "',"-," ... ," J~'." ~ ~ l~(J')t ..,. - '-, . . .' ....'., " . ..':~. .... ~ :..~, ; ", , , -~, ~ . . . . ... .. 2 J 4 5 I RIghi Si'; ;'1' Len ~ o Brllll" 0 SluggIsh SPEECH [joaea, 0 GI.bltod 0 Ablenl ;APPROPRI E FOR AGE 0 ND eYes LOS F CONSCIOUSNESS o Vel 0 Unknown OF CONSCIOUSNESS OO<ionood REACTS Approprllle Verl>aI Pain Cervical COllar 0 No Ilaclllloatd 0 No Nee 1.00 p.tr. EXTREMITY MOVEMENT RI, Ann Appropriale '0 No RI. Leg Appro"",1e ~ a:" ,.". ApproprIoIe ' 0 No U. Leg Approprlale PARALYSIS SEAT BELTS , : i~' . .. '/ '. 51,: d. Re o No o Nu o No ~ ~ ld"Y" o VOl , . ......... . u ONo ;;rill" o Yea , ) - .. I , " ! "', I I . , .1 ,':,1 ..'. ','"'r- . .', ". .'1" . . ,.',' ~ . ;f'~; : ".,1 , , ':';1,'. .'j , 0" .: :Ii,:, . 'I ;. " ;'. "".j' . ' .. , , , I \: .. Pallfl\t Hamt: MUNCY VALLEY HOSPITAL. MUNCY, P.\ . EMERGENCY ROOM .RCARE INSTRUCTIONS TO THE PAT.T CI')""/I't- _ENNo qY,)I,~'15 , {;IAY \. I NOTE: ThO .alllTWWhon and l'Ultm,nl YOII h.I_U fuctll.od 'n lhe (mcllgoney O~'p.ar1m.nl holly. bolln 'unCII,IIC(J on.:an on1-'IQuf\C)' b.1'.I "Ill}'. and DIll nc.lln:,.r\fJ,,>d 10 bI Q luDtllM. 10' M.llOtt 10 pl'ovld. corr.plell mod".. (o1IV, Your lotlowup OOCIOl (n.llned bolo"" ,*,11 JlltuuO. COPt' 01 rOUf IIJal'(,J, o1nd Dlllosl roPO',. 1111 ""prl.nllhal you Ie, twn chm)'ou .g,,".'nd Ihill you t.pQf110 Ill'" ,lll)' fWhlW O' '''"l.lullng prool.ml ellhllllmo, bvt'UIO In Impo..,b1.IO 'cCOgl'llZllllnd IIU31.11 .,lemonla 01 ,.,....,'1 0' dlnvll In It &Ingle EmelQtnc)' DOPlttmenl "lU, M"oIIl.tIlI,. rOLlOW THf INSTRUCTIONS UELOW Oil 'nd".IUd 10 )'ou. LACERATIONS (Cull, Abt.Unl. Ol,l,n.. Ele, o I. K"Pthldl"..,,,,cJean'Mdry C Z. Unltl, Olhtf'ltoll. dlIKled, chang. dl"""" d'tl, 0' 1mm.t,:t..llvt, 1111 bfcomtl..1. o 3. EIt....I. ~nd II... "'I nuh II PG'''bIf IIJ Ipt.d hut'ng 3nJ IttltYtp.ain. C 4. tr lIJound..... ~I IN .nd ..ou.n. thowl pul or IlId llIliIhl. I.lutn 10 IhI Emot~)' OttpaItmenl o.&pl. Ih. or.OIlell r.OIf'.OIr'1 wound CAN btcamI 6nfectod CONTUSIONS (Bruo.-.s. Sprainl and 611il1ftll [] 1. Um.,.. UII of Infufed 1I1111"'lltuc:lld. [] Z. EIev.1I the .tI/JCted .... C 3. Aftf*t a tOf' 41 hout1. 30 minutn IVIt/Y hour .mll.w..... o ... U.. moil' tw.allor 30 minuII.; 4 lim.. d.,a, allctl' lht 11I1l4! houl'. a 5. Rewrap....1C twndIOe. .v." fOUl how.. RtmOv. al b<<tlinll. "-move" ~utld ...,. becoIMl coId.lUiftluI. 01 numb. [] e. No~hlbe"ing.UMCfUIcht.IOl__d.ar', C 7. Your .....,. hi.... bttn lIad by 1M Eft Ph)'lClln. FOf rOUt addtd pl'oltclion. rour I.f,)', ". be ,u.Ad the following day by OUI n.ddoglll. II an, IbnotmlIilil. 1ft lound It\il havI nol b..n C&IIId 10 ,"OUI .n",,~. you Of )'OUf doclor will be Wtrd Imtnodaaltly, 01 c.aA 548.4201 '01 1M t..ul1l. Som. IINIIlrlCll,orOI can onI)' be lIOn In 7.10 dar.: Iht,.lorl. I' )'OUt m.ury .1 nol NaMa r.lum 101' D ttchtcL &PUNTJC;oST CAllE C 1. The aplin, povilSod it 10 ptOlId Iht lIoa )'OU hlvl ~urld. 111110 ttmIin in pIKe II IN timt unit" you ha.... be", InlltuCltd cWllltnZl)'. e 1'. YCMoI"llotemovtlhlsplinlin_dl,.. [] 3. Ktep cui dry .1" bmtl. follow IpeC!fc inllNdionl. [] 4. Raturn 10 E.A. immIcialtl)' " numbneu, &Ingling, or Ollltly incIHMdpaJn. , 5. c.I pl'tyaidan " CUI breaks. IooMna 0111 tauloing &kin IrnllllOn. HEAlllHJURY C 1. WalCtl IN PlIItnt CIl,'uI, tOf' &hi 11111 24 houri. Outing nonnal lIMp hourIlW...n the PlIitnt IV'ry _ houri. II.", oIlhI following DCCUI. c.aII )'OI,lf' family ph)'lbM Of caIVr.lum 10 1M Emergency Cepe. irrIInIdWtl)', .....n WIthin &her" monthl. I.CNngo In be....... 2. EaceuNe dtowIif".. or confusion. 3.1NbiIily 10 ,wNfI pt&iInl, c.onvutlion, Of untonKiou.. 4. NudIntH or wtP.nnl 01'''''''''-01. S. Stvtfl ptfIialtnl hladIc:ht. e.1'IfIIa1enl~. fwor, Of 111ft neck. 7,~pup;lol....IIIgt.....IftIIll), I. Drlinlot 01 blood or dt&r WcUItom." or nose. .. Refrain kom IicohoIic bever'OIl. lICI.llon and,"}' pain _""'''OIlgOtIhanT,tonol. I Ml.Jnllln Ighl cr..".. '.', 'TREATMENTllIfDU.OW'UP [J ,. Con&acIthe Emttgttq' o.p.ttmInlfor IhII r,lUlU .1548-4201 Nt , _dl,llortheOll'OII11lU1l101yout1t11: . B"i Relurn;o ErMrg.~y ~PL InuMOtll,lylf condiUon ,udd~nIY wotMnI, or CMfloe In .,mplCMM. o 3. .Relumlfnolmprov.menlln_d.V'.. NAUSEA. VOMITINO. AND DIARRHEA C I. Nolt\lng by moultl rOf 2.4 Mil" alii' vl)IftIl""O. 2.4 ha..." Ill", 1,)'1 vOITIII.ng f'pilOlJo. m.1r 'Lllllo O'~. ''fl' ..I ~OlU CiqJtd. on, Of Iwo 100l1po0I1' I' . lImo l.hl1r Iruqu~nllr .evul)' !t.lO m'nulfll). II vomsling '.curl. .~II OIn AdCSsIiOf\a1lo..., hou.. bvlo'l "po31ing I,quldl. A"I' III1""no in\311 qlolAnllllOI or i!,fuld IIlXIutnl!1 lor ,.Co halllt.. 1.11011 QuAnl't.... 1.2011"""1. mar be OTwen All" an 1Iddo11On.U 4.6 hOU'1 wllh "0 "'O""I'flIJ, QllOInll'..,ot clo'.v lIQuid, tan bit OtVIn AI dialled II und,,' G monthl. OIYO Ptd..')1.. L)t,,,r. Ru~, 01 HoCI1)1' (Iva,lIbllf 111 ani crllJtl.IOlIlI, R.I'I\IIOI\ 01 lluldl 10 pllIvonl dchrdlilllOll II Iho moll It:" ~ltOlnl lhlf'lg AD::,o"".lr no lood Ihould be Olvln IOf al 1001$1 414 t\oull. Allot 11&11(11 I" llll1nod 101 20 hou,.. ""Ill .nd fnllh plodllCU Ind IOn Ic)(1s InIQhl be oradu'lf tnltodUCed Inlo the dovl. Sl.ilIlt wllh ClAthel,. 10111. 01 '.eo. II vtllY\lIIl'" POllisll ov," 24 hOU'1 Of' ptolu.. dloll'll..OI OVII' '8 houri. pltilWJ Itlu,hn".." ClEAR L10UIDS PW..c1t:1 G,ngelll. 7.Up JUlt8C (NO d.ctllod.1 ptodUdl1 ::L Vc"l.Jf'r'ER RESPIRATOqy INFECTICNS U 1 O.1nolu"'''Wp.l04. C! :. ',1" Iuktw..m wOIl" b.1lhs 100IetrlPCl,atu,,, orOOlIO' 1h3n 103 d"li!QOS loctalfy A,':,,'t. bundling up wiln dotn..; lhis 1niI)' InCIctlSct I,vtr'. D 3. t.ll'..JT,..noIIOfI.Ylr. dOlo1g.. D'. lna,," hWe! InLlk'. IIJPOOill)' will...r.lo Plh'Clnl deh)'dtlbon. [J 5. NOIlI, phrlidln or Emo'ooney D,pl. IIIOmptl'~lu'.I"04 dugr".. 01 0"11". [J 6. 00 nol UIO.apiM With thildren unde, 17 ,03" ol.g.. ABDOMINAL PAIN [] 1. ThM, II insunlCionl h'idtnca 10 wlmltU Ihcr ~noSil ot 4(...10 abdolfllnll condition. lequVang haapiUklation. ThI. ma, Change with 1he (\Ul&OO of bmt. Fot)'OUl' &allry. l1>>U &hould ob"......1ht lOIIOwing ruIIs: . FOllOw IhI ordet. O..-n 10)'OU ''Galdlng dI.Il, mtdone. ,Ic. lnct.alinO 'nd INtlllI.nt pain. 6nct,aslng lOI'nollln abdom"n. dill.nbOn PIf$lAl.nI "omibng. ''''''f, may algl'lll)' . ~ If'lCI ,equitlll re,of'aw!iOn belo" IhII bmI. In such an h'nt. ua l1>>Uf PG'sonaI pft)'lidOln OIlho doctClf laIUng hi. calla. If ,OU It, un.1bl. 10 Ioc.t. lhOm. UII Emelouncy doctOf IOf lultttlrtinltructiOl'll. Wal:'l' Vll";""" i'f"n .;,.C Jllll.O KOOi.\od OLooD PRE&&URE [J 1. DINInG )'OUf .laminatlOn in tho Emlroency Ot~.m. )'out b'ood pralSuro was found to bo ..vlllId. A linglO b1tod plIISU" dctle'min,ll.:m lholoild not ~ ulld 10 mak.lho WOnoSlI 01 HrPtltenslon. Thll il PI'liC'll..,I, 11\18 olin ,Iovllioo lound in &he lometimel -cn:u~ almo.pher, 011"" Enwtglf'lCy o.partfl'Htnl. VI, do, hoot.o't'O'. focontmond INI rou hI...t )uyr ptOllure Itd\tdlll'd b)' )'OUt j)CI5Of\o'\l phtsi> 'an and . Cl<<iSion nw:ll at.GuIIll, tIIOd lor ltlllmunl. MEDICATION PRECAUTION [J 1. ThiS modcbon may nu,. ':,o.'SiI'leu. 00 NOT DRIVE. OPERATI! MACHINERY, OR DRINK AL.COHOl ON this modIC4l1On: [] 2. The InlibiolC W1I La". ,...36 hour. belot. you nolict III'WI1. la~ mtdCliOft unld COmplcl~lr oone. e 3. Tok.I mtdabOn W1lh lood; . 04. Tiki ActlaltWlaphtn lTrlonol.elc.).u in$lfUtlod lor p:lln. OoSOI']tt:_ pllWp.IY01y" houtl. a 5. Taka lbuprol.n (Ad't'il. NUj:ftm. crl...) '-llnall''''tlod 101 Po\in.I.I.." ....,In lood Doua-:_p'11a tvlIY __haUlS. Disc.I( ~hp ..../ p~ ",4-t<!,u...J OTH~R INSTRUCTIONS: ' Dd%/Io\f~ 1'-/ "'~..,}""("''''W fJVI,cIC/,<.,..,r /l(OTR."J fO~7 /,0' Gll: e. ~ DA. II! _ ;"..(''':t~ I.JE:'~ IIV..-:'M ~t tc'...c.4"'J //1-1..., r"vc,. ~4" ;' I hereby euthorlzo and ocknowtedgo roceipl of Iho Instructions Indicated obovo, I undersland thai I havo had .",ergency 'rea',n.nl only, and tho I may bo roleased boforo all of my medical probloms ere known or Iroated, I will ol/3ngo for fOllow,up care as ,"slruc:od above, V a~ t121. ~/Lfr.J_ PA11ENTIGUARDIAN SIGNATUR~ OOCTOR.NURSE SIGN"lURE Dfoll INSTRUCTIONS: RETURN TO: o YOUR DOCTOR 0 EMERGENCY DEPARTMENT TIME: DATE: o The above patilnl hit bton undtf OUt Clt. from andlll!>>ltlortll.rmlowor1lllchoolon '0 o L.....lionI: '" , ". ..' ..' - "'........:..\-............. ............... .-~_. .. .... .____ ..' I" .' , ...,. ..... . ...... .~... -'. "" hi '-.':'-.- "-:~.. ".-r--- .~ ...--~- ~ . '-.. IIUJIcr VlU.LU IIOSPITAL RADIOLllQY IlIlPOR'f CLaIUI:, CIIIU.& IIIR 192-56-1'45 Dr. Adu _~ DA%W or~. 08-16-'3 CIlRV%ClIL 8PIJlII. The vertebral bodiea are in good alignment in all viewe of the cervical Bpine demonetrating normAl vertebral body heightB and diec spac~s. The posterior elementa are intact and in good alignment in all viewB. The neural foramina are patent bilaterally. The bony archltecture and Boft tissues are unremarkable. DlPR&sSI~. Normal cervlcal spine. r,rnnaaq SPIn. The vertebral bodies are in good allgnment in all vlews of the lumbar splne '" demonstrating normal vertebral body helghts and'dlsc spaces. The posterlor elements I <.'. are intact. and in good alignment in all views, The bony archltecture and soft ' ,'. :.': tissue. are' unrlllllArlcable. ' , 1":---':' -. :.' , , .' DlPllU8I~. ;~{;;',~~~:', .,~ ,'. (,:,,:. .. Normal lWllbar .p1n.e. " ~'" "[ .", . ,', t. : " ;:'" RIGB1' DIP. ," '.. ~ '~i"I": ~,~,~.(.:::.~ :.:', ,I,. ":.~".:' . . ./ ....::~. :::.,', . ..: ..,.:,..\ '.NO. fractur~,' di.locat1on, or other. abnormal tLndlng ie seen. }.;,.;....,,'.,~...".'.,.';,',..}:,:,0,:.t,.,z-',.i..',.'.,t.,,'!'.~~,~,.,fl,. .~CII,..., ',',: .-..<~.. >'.; ~. -1' ~ . ..."";:f.~ ~:;'''''::'':~''; :,,~:"."'.;: ''''.:' Negatj,ye. . ':"~~' :'~ " ~'.' ::" :' ,:.::;':;'<>-';:~~l1b'~""~'" /~"~,":';,,;';? >1,' '..,," .. 'DI,:.08-17-'3.',. .,.. ,"',' , . . . ,'.:,~' '.' " ". ' ;'" ',' TI' 08-17-!l:r '. , .. ;. '\',' , PI.......' I:: " . , " . '" ., {. ., ',' .' ..... ,.-..., . ..~ . .:'.... "', .. , . ~." " . ChaD' J'oou, X.D. ".',1.'," .' .... " ."" . ',~.~/ ,!:;.~:' ~~ : , " ". ./l~ " ..; ,''t' ~~.,.~,.~;..(. ..e.;~~.4!"~:"';':l.'" ," ,..,..... .:"~.~.,,...;-. ..:...\~..o::...~,..,. .'...... ...-:. ....- '.,.. .. .... , .' ( N I' I I ':i'il.~'t'i:,~.L""'<"~\'"~''' -,' .. _ ~'~ ~ ,~~,d""._,'t'+,,,ti~7'i'I__ .. ,-,.. t'!p,~"~Nfid~, M .... >..:_..---",._.,-....---.....,'_...,_..._~_._-,.."":~~,.;""'""."", . '-'- ~-~~.,..._-~---'....__.. '<J --, , , o . , ~.,.__....-..-...-.. I. . . 'T""'_-'t~>.,.,VJ,\_.............._,;........:_._.._".., . .!~. . ' PERSON INVOLVED Male 0 : MEDICAL INCIDENT/INJURV REPORT 'Ill N me) tMiddle In,tial) Reponed To Dispensary: Date: f' / / ~ / Q Hi' ~tJ PM I - Tim.: o C] VII SUPERVISOR: EMPLOYEE I Department VISITOR 0 Home Address tJ, Job Title - ---- '..... ) Home Phone Occupation OTHER 0 PropertY Involved 0 : "', . . "",_...... -. Reason lor Presence allhls FacllllY Equlpmenllnvolved 0 : \ Oesc/ib.e , No atscrlbe Elletly Whit M'l)gentd Why II H.pp,,,td. Ac1ion T....". II." I"jury, SlIll Pin o' Bocty Inluted. If Properry Of EQuipm.nt Dlm.ved. OtKt,C. Dlm'Q'_ ,. Oiscription ot ItIness/ln'ury '1 IContlnue on Reverse) Was Physician Notified? Ves 0 Was Parson Involved Seen By A f>hvician? Ves 0 No 12" Was Person Invol ed Taken To A Hos ita I? Ves N ~ 2, IMlallmpression Illness/Injury NOel' Was Family Notified? Time Where Veso Nolld"'" Dale / Date 'd"1 Physician's Name Time Where /}f 1/ If -,/l.. , Indicate On Diagram Localion 01 Injury / J TYPE 'OF INJURV o o o o o o. ~ Follow.Up Reviewing Authority OC.84 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS MEDICAL INCIDENT/INJURY REPORT - . ' I hereby authorize the performance up~n~ . ~G~.J C'~Gd___ Nun. 01 PaLlln' of the following procedure rioumeS5 and probable outcome have 'been to me by anyone concemlng the results To be performed under the direction of Dr. I acknowledge that the nature of such operation or procedure, I aplalned to me, I also acknowledge that no guarantee baa been which may be obtained, _ . I understand that in comenting to the performance of this operation or procedure, I am authorizing as well all procedures which are ordinarily Incident to the procedure including the administration of such anesthetics as may, be considered advisable. I consent to the disposal by medical department authorities of any tissues or parts which may be removed, I consent to the performance of operations and procedures In addition to or d1Uerent from those contemplated which the above named doctor or his associates or assistants may consider necessary or advisable In the course of the operation, ~ ,v Q . ,a.l1A UOJlJt- a~ent or person authorized to consoot Cor patleot . , Rela~onshlp to Patient oC person slcnlng IC other than Patient institution c- ~Q.:tm I II alc,3 , f L"1'\.,. U Date BC.77 Inmate Identitilition D.O,B. 1 {l C;/ ~ (; SSN I C1 .2- - S-r., - 154 S Ins!. No, (:)fJJljlf)) Name CJ.aAl..J~ .. COMMONWEALTH OF PENNSYLVANIA BUREAU OF CORRECTION CONSENT TO OPERATION OR OTHER MEDICAL PROCEDURES . OC.7S Inmate IdentiCication Hypersensitivity D.O.B. 1-/f-~ ~ SSN /9~ -05'1- /9~.5'" Inst. No, C'.! ~/fI~ 7 Name (jf;~ (/(1c1'a.-/ . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS DISPENSARY CARD Date Medication or Treatment Signature Lincla Grana __ ~~/_~j,.t-'J":'V,+-.~. SC)h4 ~rer) _ ..../ -~ ." ~\ Card. Continued Date Medication or Treatment Siillature :SYl J ~. - a 5s..o I'"" . -" 10 .... - . . DC.78 Inmate Identification 0.0,8. 7 - / 5' -~~ SSN I q ~ -,50 - I '1'f~ !nIt, No.Of!::!.fI.f:J.. 7 NameCltAl/ U'-'~V COMMONWEALTH OF PENNSYLVANIA OEPARTMENT Of CORRECTIONS DISPENSARY CARD Hypers.n.I~YI Date Medication or Treabnent Signature ~, /Y! i ( -. ~ _:i ~ ,0:,._"",..&,,\ . . -- \.:.-......." -' (Over) Date Medication or Treatment Signature 1 L - c- -~..... ~_.. i5r;~miis Way. D : - -- \ , . . ce.7S Inmate Identification D,O.B, 1-/' - -t- (, SSN /'1;{-~"'/1~.5- Inst. No,CIJ ~rI~ 7 Name flI~,~ aLl'tV COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS DISPENSARY CARD Hypersensitivity Date Signature Medication or Treatment .' ~~' "cI X /i X ~ &V~ : (Ovpr) "-:-. -., Date Medication or Treatment SlilIature ,; I" . " j:j) l'? . ~,~~' , J- &.1: e;-~ - <::~ ~~~. -. - :2........ ~ - . ;;) 'J-~J : - - DISPENSARY CARD Jnmate Identification D,O,B, 7- (~- - G:-'- SSN /92. _ sr.:_/7C{.J- Inst, No, (j5 st<ll.,7 Name Ci!~ ~"----' DC.?S COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS Hypersensitivity Date Medication or Treatment Signature -' (Over) " --.., , \ Card. Continued Date Medication or Treatment Signature s~ a - t!": , v..A "'- ,~ ? "-- ~ eo ~ ,.:..., ~;S, t.a-t. \4v- )... DC.78 Inmate Identification COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS D.O.B. 7h/l.{., 1'1 ;l.St,_/S\l~' SSN DI5PE~SARY CARD Inst. No, 073", I{,) 7 Name UCJJ....~ H,'penensitivity Date Medication or Treatment Signature ~ .~,4~ . CPe. ".t.. v/~,r'I.,......f, ~ ,/. '11 ")-".( :;flltt:, 1\ i~ .- "I II..:./-I..J J " ([ t, It' I. i', , (/,;u;1.. Uki:.. ". , 'i,..'......,\,. ; j' .' \.....; .. '" .. \". " 1 I' l' .l.I.; -... "ll.':"tl.1., ~ - ~ { (' " ',/ -" '11' I ;/.....t '! t'! t '..t - '.' . I . \ ji. r.',' t (' ...l I'-" _~\',,,l'-. . . . " ' " .A' i' , '. " r., J '~', I r. ..kJ-t'l" ' 'P. ' j I I \ . L"'. - J . ..... ',. ....... ;'." 1'-". . i--I/;7 '; /I '-, ":. ,i I /,- _;, ":' \. ; .1... . l ..j... l 1',,-' f ,,-I \" .'~'"-' '- . ".".J., ..'d &,'" ,t .t... r </ ~...f,L..<.:t - #d"....,,//I j _~!L .~ ..... '"' Dis ensar\' Card. Continued Date Medication or Treatment Signature ~~ ~ r - c:. ~ ,....c9 ," 4F' . ..L~ ~ .-< ~ r ,Vo/"'-<-G re:o Hartz, MOl ,- I ~ V7..-.. ~ Z ,.r"L- , /. )-a:... , p. r,- _ -, .-. Dis ensan' Card. Continued Date :\[edication or Treatment Signature - cP ts.:(::" D ?C~ L - .. " / -c 'C - c... /" r; ._~ (J,e.4 '" c; It..., .!-,-..:> ..,6 5C~ .d?R.I...:../ ~_ 'J ~-.. :::.;o..,~,/( OC.7B Inmate Identification f...J (~ 'tt- Hrpersensitivlty D.O.B. 1-15"- Co C, .... SSN /fj,;'-5'6' -IVY.J Inst. No. (.'/3 '-1'1:2'7 Ill' , Ii~ , Name ~a'~J Ja~~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS DISPE~SARY CARD Date Medication or Treatment Signature t, ......tc/ - . ......" -n .~..,,'6- ,~ ~ 'S" t----<>- ( ...... ..:.. , '-- ..... .... Dis ensar\' Card. Continued Dale Medication or Treatment Signature , . / ,., ... . ~ ....... ......... " S t4: ' , -""'c..4........ ~ ~ ,~,r c:......., .:-P..- ~ L t'. ~ ..A-~:. '7"'.-r-7,~p ~ ..,<, ~, . . ~.......,-...- DC.78 Inmate IdentiCication COMMONWEALTH OF PENNSYLVANIA oePAR~MENT OF CORRECTIONS D.O,B. 7 -I.,:) -(, (, 5S:-: 1'1 ~ -.5 Co - 1'1 ~S Inst. No. (I i3 t/l{;l '7 Name C,e~~, Co-..~ DISPEXSARY CARD N\i(\. H)'persenslt!vity Date Medication or Treatment Signature i It,;;' (/ , . c"^""" ~ j;))",' 1 f. ~,~ c: , ~ . ,!. . iL..--<. . ~a~ e~ '-~.~ \J '-~ / ,?-S', oS, ~ I'<<~ .:-<-; .;t: ....e. '$ , , /.' .- a....u< Co - t-..-" ~ t:~ A.-.......... ............,,J.-r' ...............-P ,--<4 ~ , ,~ G~ -- A ,~ ~,..... " t"_-=-- ~m~m ... o't.;:.~ '.,/~.... -r- ,( c...--e.- I r- :.,t.P., C/ . ," .,.. ~.;.... ~:. 7-;7.. c:......__ , ,; ..... , - . .' --~.---" v - .-..... - , Dis ensan' Card. Continued ,. UL-.- UU !,. ',', .. II ,t. ., , f. I .,,/ r: '.. ...... DC.78 Jnmate Jdentification ?' )(. C , H:'p~rsensitivity O.O,B, ')-/j--&(:- - SSN 19,/1" -56' ~ /'1qJ Jnst. No.c.~6 <(t/; 7 Name ell!:.it; (!~ rI(L..- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS DISPEXSARY CARD Date Medication or Treatment Signature I ~'~~"I - (1 ,::>'7< .-? CI , /"'I./;'t .. \,1..1," . ~ I. ,/....,. . ~ "/'-".' ...!.../'--C". k............ .. ~_:"L ~. I, t I" :, " /..... ...-' ,;,.,A ./.r-.. I (..It v /" -' - /1"--- ;. 0" , r; ,::..; ,/ . ""',4 _ . '.AI" c. j,'i '. , , '. .' /. ' .. - '- J...., . ...,.,.,,/! ~. ... (' r' -td'tc .........' ,~ ~t.., ~-t..-- .,..t'___ A, ',/ It' / -<~.~....r;:'; I'/-~ "* ~.,.,,~ JV' /,/,../;l!, -- Dis ensarv Card. Continued Date Medication or Treatment Signature . ~-9~ S. I J. ~ /~ ~ a..v- / 0, ' If--J \ ,4. . -r~ :} "- I. ., ; ....-1-" -<:VI ~ -Co - Co A,,~ ')< /~ Robert Manenkoft. \clan ~.ssls\ant Il ~/#'c... .~- II .4 I' '1-(,-'7'1 'I.l. 't ,i.v,C:f ~ li/~' .. ... /~. 1(. 7-9 ~ OC.?S Inmate Identification D.O.B. 1- /j-. t t ss?\' /'1;/ - 5 ~ -19~J" Insl. No, () 1.3 ~4;/7 NameOlMJI., (]~~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS DISPE:\SARY CARD 1,1.f. /J. Hl'persenslli\'IIY Medication or Treatment Signature /: tlUl. r / fi ----- LL J1,... / r~-AJ V I'-r-I~ 7.j-~ 1Yt) ~. UJJ , , . .I X, n~ ..,..,..J. ~ 3, ;tt........ 1'3 1, ~/,If-' Robert Manenkofl, PA.C ys an Assistant y-/~ v...... /).. - '" // ~ Y-)v ~ ~.t '{-,I. 0 ~ /?T / / .' ~v US&/lS wi 'f.- . t't....,. .. - . p. ~C1UllStod Sick Call ~ -~ Date Dis ensarr Card. Continued ~Jedication or Treatment Signature L.... C 1 l'L6 ,y\..(...:J No Show for 1 ~.1-U- (~--- ~ o /f, ~/#-c.. ~ P.oI:t:t '}.a:.~~""~, PA-C Phycl. n ~, ~ ~1.<~- 0, ~ I'r: o.k./..-.4- .L.'. ()C; 0 0 -;z . 1/. 0-0- k,: ..I , - ~(.. .-k. ..... . . , rJ"'^ f... (.. a. .' c.hL.' fJ /. J~ -:: fIJ.... X'" I T :/;r I -I- J. , k , hJw/"p- G P.ol;l;:: 1,!ar.snkolf, PA.C ...." . """ ,,;J- /"7 .,~~ ~.., S-.___ p..." /~,./~ ~~r'_ ~~<a ~/-r..~~ ~~~ 5""-;; ~ . ....:.~.. 0."; ..,,'-r... r.-J..J DC,7B COMMONWEALTH OF PENNSYLVANIA OE~ARTME~;T OF CORRECTIONS Jnmate Jdentification DI5PE:-iSARY CARD I ,; f{/}' Hrpersensilivil)' O.O.B. /'-/5" - ~ SSN / f;J, - 5" b - /7 fls Inst. No, 06 t( Y':';> ;7 Name (If.Ci/~~tL- Date Medication or Treatment Signature ,~ ' -.,;~~ ~ I t<. I ,..,? /-t) ~<-- - Ci / /' /-(/ .; oS ,..,- ....c..I__~ ,., . 1._ 1r\~C.:\ J"I"\,;~ .."" ..,..,.~._._,~_. ~ '\ Dis ensar" Card. Continued Date Signature ~Iedlcalion or Treatment ,1'4AI- ~Ii ...., - ~ , ... lr<. Ir' . ", ~ ~ ~ .-<'A,.. L) .. ::,,:, ~-:~li., .,t; ?net! .d~ 6.d. ~ ~. (." .hJ .",~ S'Io?- 9y S, ,oro o. ~ -~, ,,&.. ,:~ . 11, --r~ ~Q I ~ ~I.I!J1X/~ A. /vWW /~ - c... ."-.-'/ " Robert Man~nkoff, PA.c .......... ''':O'C'. --- ,.- ---- ----- - (tJ& H)'Persensitivlty Inmate IdentiCication D.O.B. 7 -/6.- " SSN If:L - ~~ - /fP'~ Inst. No, 06 r; f",;2. T Name atlt~ &Jt(.../ OC.78 COMMONWEALTH OF PENNSYLVANIA OEP.\RTMENT OF CORRECTIONS DISPENSARY CARD Date Medication or Treatment Signature (r .1'1 5, I~ ",...,. ~M ~. h..,.... c:.. riCo o. -I- 000 (!->oo. fp r.! .~4 ~ -r~ '.J ,,\~ / .., '. , ;?-. / /I'".a, . , . -r.<-.,.~.J ! "';-4 . '~aJJ - 'J /#.,- Robert Manenkoff, PA.c P cf I., -,.:ootC'f /f. / C- .- - (' f,-J.o-'i { S, Il{ov 1/, It. /l. 1:- / ~: ..U .t. .II-U; /Y r ~ Robert Manenkoff. PA.c sielan Assistant ~,C J.I -;tt .$ v }!-< '..... . , , -:~_..~-_. ~. --, ...... Dis ensarv Card. Continued Date ~Iedication or Treatment Signature No Shcw for RBql!e~e-I S:~!: r.,ll ~d-~ ~ . (<'?L . , c.-rrn to{ I ~-C'f".I, - ~ A-.J~ 7 . :1.r ..!. T'/LJ /'c. X. I~ :iJ / /<. ~- 10\0- II $I~ ,. c.-1l. . '-< 'c ~ ~ t-.P ~vl; - ~or-I - jJ .-4:. ..... ..... - ... ~ -.... - " -. ...., De.,s jJ K,f., H)'persensitivity Inmate Identification i I, ~-/ ~lJ /ft;?- st.a - 19'(:;- Inst. No, O!?> l/'t~ 7 Name tWM ~. D.O.B, COMMONWEALTH OF PENNSYLVANIA Ce?~RTMeNT OF CORRECTIONS SSN DISPE~SARY CARD Medication or Treatment Signature -" ,oC-G-'t ".J- , . - /l ~~_c:. Robert Manenkoff, PA-C , " ?-/~i s" ~ .1/, .....- Ivo0 (j, J!,j.(l. ~4-c. . -.......- ,~ O'~ 'f~(J'7 lnst. No, ad Ihd~ Name DIAGNOSIS ALLERGIES ~...;I , '? <:; ., Monlh Yoar PHYSICIAN ~IEDICATION I~'u~f .. - ~.~c.""" ~ DELIVERED . INITIAL REFUSED . INITIAL " CIRCLE DATES NO SHOW. 0 ~. , . 'I"""'. "',, ,,',,",',,"" ".,,,...,,,,... .,. ':<. , ,IMINt ... . ~~ L 1M ~ ~" / (,.( !Jill" ' It\\ START STOP DATE DATE 9'3' t7P" ?'+? II' ,;J. Ijo' " 'Pl:- I> qft6 ?J~ ~Y'- .;tSo~ r:-:.L '^ J 'l1J' W~' f1~~ I~; ';'1 'fit a,l.D ~1 .....\"!. . l" I'-.Lt ~~l,4ol., CI (I' . I t;J.-. ...:2,-0 ... L'';h~~. ~ R'.(i .tlo"" ~...t \.;; I )I...~' Y 1 i~t"" ~k"'a./.i+1.. . <( 9~1 1/1 ?5O /rx( f?iD cL t.i t1J..;.uv ., I -m 9/v 9/.).1 iO/1I 'J<nr,e',,;,- \ C, "a'( ,." "'" r '" ., ~ 1_. U.!ll!:! ,"- Kt.i::n.. ' qf',1'l I.'~ rJ. " 71:::>. Yf8~ I " ~ :J.Jt5 ID I .1 loA.. ~;.2.LLl.o!ot1< 'i IN,. ~~\ I'''.J. ' INtrlALS NURSE SIGNATURE -tAL ,J4,u't~.L/ 1'/11# SHIf'T ~ DC.i3 CO~I~IO:-;WEALTH OF PENNSYLVANJA DEPARTMENT OF CORRECTIONS MEDICATION CHARTING RECORD I/' IJ. ~I $, I , iJ~ . II $: ~h" Il~ ,,,:"!J I ~'iVY'~ ~ 'T' I~ I I I I , I I iE~ , , I I I I I I .. "" I ~ k. k I .. :'.WY. l! 1< r. ,I I , I , . . I , I I I I I I I I I ~ ufll I \ ~~, I SHIFT INITIALS NURSE SIGNATURE Inmate Identification 1'1-',1/' D.O.B. SSN Inst. No. t'.j t./~,9 7 Name et:-.--f', ~ START >TO? DATE DATE m:DI':,HIOS C(/')7/01" li'IN kl! o. TES H.ur 1 1 1 , s I . I : I. , 10 III" I" I.. lIS I,. 1:1 u I II :0 III :::: U 21 U :. :: 11lI 2t 20 ; I I I I I ~ -;-, I I K.;~~ cr I I~ ~ I 15'0 "1' I t'J::t;;. I iO/~1 I ,I/~ X {)',,-r:;;:j /'- '1 - I I I I I I "',~Iu;. j;$J ~t<l. "-'~' 1'P. I I I I I I ~ (~<:I h ~1"'I(lIv.. .I.(b:I$'&1~ I I~ I I I I I I I I I I I I I I I I I I I I I I ,-, I I I I I I I I I I I I I I I I I I I I I I COmlESTS : . . 6 (1 <!t/..-i 7 Inst, So, ,I;.' ;; 1 .Ie !///i,j' Ii /2..1 et-J ) S.m. Q" /MZ I~'i'" Yea, DIAGSOSI:; ALLERGIES PHYSICIAS DELIVERED . INITIAL REFUSED ,INITIAL 4: CIRCLE START STOP DATES NO SHOW.O DATE DATE MEDICATIOS Hou.. I 2 S . 5 , 11' t 10 11 m IS 1111511,11 1 11 II 20 2 I ZI 23 21 :5 2C 21 2S :- ",I., ~f1'4~" Y r.L I I 7j, "14 'q . J , . . . I . I j,1(""'1 'f ~ 14- I \ I ~d ^ IcI.... 't U. III . I 1-1, . I J!1 I '7f::t'J... 1~ f..:~'UU- I R,i. y:. &a.tp. Cf '1 fit I 1-rJ.' "I ~ I I I l "" -I ..,., " -:I I I IMI I t'//;2- S/~~ ~~ S(I ~ I v F-" . . , I I (3/f)1yJ 7 ~ u/u I<E 'H' ~ I ,... 04....:- rJ, I 'L/l I I I Ij In , I '?fI,e; 'fie 0"" 1 ?A I . I t'~ ~ l.: ~ h" I I rt;u:t~~ ~ I t' I I I '8/n , -:"C I /1 V T I r. 4"t.,1 ' '7ft "f I t':S'1j: II r- T I f/i"t'l t;l!. X IJ.~ 4 I II l.~' I I I I ~ t~ If/~J ':) IS ;0- I I ',1 "I'P n. 1 I I I:t <: I rkl '(1/1 (" f.~ ,~~S/~ . ,-.;. I ().J J.Al. . 1 ,.I., ~~ I '11/'1 '!'j.u t:/ q, ,1: I . . . , , I I I) e.<.- I I f/,'),I'MI)I./-..4. CJ ( /A 11 I I SHIFT ISITIALS NURSE SIGNATURE SHIFT ISITIALS NURSE SIG,~TURE K.Q JlJU.J.fi..~';..r .(!J /.',1. . 't!~, uk!- /../ / ~ /_ ./"" f /J. A ,. DC.i3 Inmate IdentificatiDn O.O,B. ~ COmlONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS SSN .. :\IEDICATION CHARTING RECORD Inst. No, 06 <I'f.J.7 Name C/..a..<.k., fa.d_a.. . . START ST~~ I DATES OAT:: DAI~ ~I:::.fi:.\ nos H... I 2" I'" 1<'" .1.11011I1121",..IUllO,,,IIO It "1211%1 n :. 2S I:. 2'1 u " ""I, ~, '(I'.... I , I , I I I I I I Ih, qt.. (I.. I I I I 1 i,.., t.~ ... 1 1 I r I ..pi": ,,, 'f I I , t:' " ,'tUi~ I I ,'" " 1 I I I , , I I , I I I 1 , I I , , I I Ii I I , I I I I 1 I , I I I I I , , , I I I I I I , , I I I , , I I I , I I , I I I I I 1 I I I I I I I , , 1 I I , I I I , I , I I I I I I I I 1 I I I I I I I I , I I I I I 1 I I I I I I I TT T I I I I 1 COmlE:STS : ~ . . Date of Birth I Aie I Race i ." Heillht I Weillht Puis., I BP , .1 Date of Report 7/15/66 25 C F 5'5" 122. 72 110/60' '1/1/g2 . Hearinll 'see a\:C!iCll'eter testing Visual Acuil)' (Distance) see telebinocular testing Rilrhl' WV 115 SV /15 Rilrh t Uncorrected / Corrected To / Left WV 115 ,SV /15 Left Uncorrected / Corrected To / Immunizalions Type Consecutive Immunization Dates .. Remarks ~e~lo.lo "rood 1;/1 R/O., Or 110.1 'iI, ('^"" mvr loon I Urinalysis Seroloi)' (Specify Test Used and Result) Specific Gravil)' 1. 040 Sunr I Microscopic Blood Type and RH Factor IEKG , Albumin I RBC IWBC IHb I Poly ~LymPh I Mono 7 EOS I BAS I Abnormal . 4.71 6.6 14.2 49 ' 43 1 0 Color Hair I Color Eyes ,. I Build I Temperature Bro.n Hazel CJ Slender Gel Medium CJ Heavy CJ Obese 96.9 PhYSical Examination Abnormal Abnormal Findings - Describe In Detall- Continue on Reverse Side Norm Enter Item No. 1, Head. Face, Neck, ScalD x 2, N 058 X 3, Sinuses ^ 4, Mouth and Throat x 5, Ears x 6. Eyes-Puoils x 7. Oohlhalmoscooic N/A 8, Ocular ~fotlll;y x 9, Lunn and Chest X 10, Hear; X 11. Vascular System X 12. Abdomen and Viscera x 13. Anus and Rectum IV~ . . 14, Endocrine System x 15, G.V System x 16, Uooer Extremities x 17. Lower Extremities x 18. Feet x 19. Soine x 20. Skin x 21. Neurololl'ic x 22, Psychiatric LV'" 23, Pelvic x Teeth see dental chart DC.GO Inmate Identification .. , D,Q,B. 7/15/66 COM:'IONWEALTH OF PENNSYLVANIA DEPARnlEST OF CORRECTIONS SSN 192-56T1945 . Inst. No. 084427 REPORT OF PHYSICAL EXAMINATION Name Clark, Carla Abnormal Find,"p ~.mibe in Detall- Enter Item No, Remarks "Ti::;/er FiloJ" , , 1. SIP abortioo 3/3:1/92. 2. H hosp/c:p's otherose except childbirth. 3. On no rreds. 4. NKA. Health Status . HOUSING NO LIMITATION RECOMMENDED LIMITATION RECOMMENDEi> AS FOUOWS,: c;! Healthy 0 Acute Disease ,_ x o Chronic Disease o Disability (Describe an)' work limitations or conditions refieclini Institution pro&,!,ammini.) PULHEST 111 May Participato in Organized Sport, Yos .2!..... NCl_ MEDICAllY ClE.lI,~ FO~ r'::>OD HAtJDlfNG ~o Ex en Signature " 5/2/92 Date . . . ' This information will b~ trea:.~d confld.nually Par; A: Family H:.:orv I Pan B: Family History of Disease Alive X Cause of Death Do you have a Family History of: YES !'C 1, Fa;her Deceased l, Diabetes / Alive J( 2. Tuberculosis / 2, Mother Deceased . 3. Henrt Disease / 3, Siblings -I-- Alive X 4, High Blood Pressure / Total :>:0: Deceased , 5, Cancer -f.AJ.h4.r / 1'1-10 IlL<-<- / 6, Disease of the Blood / (Sickle Cell, Hemophilia, etc.) Obstetric/Gynecological History.. Women Only . Part C: 1. Date of last menstrual period: /-9l- A~'D"""" /h....rdl. .~'/ J<-1<h . 2. Date of last PAP smear: ,4tJr / / 1') / e.J?z... 3. :':umber of pregnancies: <; Number of live births: .:;. I A~r -I I Co """ 4. Have you had a change In menstrual pattern? Yes No..lL. (Frequency, amount of !low, etc,) 5. Have vou ever had a female disorder which reQuired medical or surgical treatment? Yes No ...k.. 6. Have you ever been on birth control pills? YesLNo_ Part 0: Drugs. past or present use Yes No Part E: Give a statement of your present health I.Steroic!.J ./ 2. Tuberculo.ls medic:.tion ./ ;/e~"';f~ " Ok'l 3. Tranquiliun and other sedativu ./' 4. Insulin or tablets for diabetes ./ 5. Dlt,ulis or heart medication ./ 6. H:gh blood pressure medic::stion /' 7. AnticoaiUl~nts (Blood thinner) ./ S. C13uc:om3 motdic3tlon ~/' .. , 9, Alcohol "'" ,.ttG't:.J4-!t'lt../. 10. Tobacco ./ j{ 1'1:.. ..c:1'V~' 11. f-bvI you ever uud: C t" ,t. e..;g /' Bubituntel (Downer.) ./ Amphetamine. (UppeD) / LSD (Psl'chedeUc Dru~.) / Heroin ./ ~l3riju.n. (POI) /' 12. Prelfncly on Iny oUler medication / BC-65 Inmate Identification CO:\fMONWEALTH OF PENNSYLVANIA D,O.B, '7.. /)"-{.,(, BUREAU OF CORRECTION SSN 19 :J-S"Cr-/iQS- : , INMATE MEDICAL HISTORY "'/'" Inst, No, C'P 'I - Nome Cktrlc. c2ttv-I.:o... . (Over) 00 not write In thls Ipace . . ' Part F: S~'Sl~m R~ :~~\\' Health Services Only Have vou ~v~r had cr do you now hive Yes No 1, Period. oC un.on.c:o'JI,.... heacl3ch.. /' 2. B1ul'Tld vlslor. 1/ 3. Doubl. vl.lon 1./ 4, Ch.1l ..In /' 5. DICClcull\' b.uthln, ./ 6. Tubffcul",l. ./ 7. Whuzlni or '.Ilhm.tlc al13Cks ./ 8. HI.h blood ."ssuro 1./ 9. Cou.hin- U' blood ./ 10, Stom.ch dl..... (1:Ic..., .le,) 1/ , U. Llv.r dl..... or h.pallll. (JlundJc.) 7 12. Gallbladder dl..... or ..II. Ion.. 17 13, V omll blood ./ 14, Black (T:uT~'1 bOIVel movem.nts 1/ 15. Venerul dise:lsr 1/ 16. Frequent and,o, p.lntul urtnaUon 1/ 17, !(jdn.~' Ilones or blood In urtn. ./ 18, SIVolI.. 3I1d painCUI Joints / 19, Bon., lolnt or olh.. deConnllles ./ 20. R.cur:enl b..k ..in ./ 21, P...",,!, /' 22. Froouenl Ihou.hts oC ,uicld. 1/ 23, EolI'DI\' or ,elzure, ./ 24, DeDrl!s.lion or excessi\'e WOrtV / 25, :\er:ous trouble V 26. Allerlic fiJction to serums, 1/ Drul' or m~d;~3tion ,- Do \'Ou h.ve .n': oC these .hvslcal lid" . , .., E\,..I.sses ./ He:ltln. :lid V Broce, or b.ck SUDDOr! V Arlincl.llimb. ./ Fal,. leeth ./ . Part G: Hospitalization History - Health Service Use Only (~e approlCima;e dates, names of hOJPita}!physlclan, diagnosis, surgery) ~ =;tCdt.-tr:1.1-r.. ~e(f /..J6.'(/#~d.oI t7A.tdec.. &. r, " ' /;// ~~t.. ~ /I I I . : , /~ - tLdut ~.../eL. ~("~J <r:- / _!/ i.- /l,./,tf ,5"-/-fll... Oate ..... ' Signature of Inmate Oate Signature of Reviewer . l Part A: To I:.e ~omple:.>c b>' reterring InstiNtlon, ReCerred to: Pr ReCerred Crom: mJ . Q/r:u. ~ Appt, Date .3/:l. '1/ If {I Appt. Time' ,;J.. ~ 00 Drug Sensiti\'it>.: :0;0::: Yes (Speclty): n c !L-)'..!:.u..)\. t7 tJ Q.., ~ . Current ~Iedications :t.,d Signuicant Medi~atlon History: !!fsent Illness: (Include Signi!lc:mt Hx, Pertinent PE" Summary of lab and X.Ray studies, and reason .for refenal) CUtt1.u.rJ::1n..J D meAt-. Ii: (&-t(]'~3 ,v.~ fJ<- c,; L ' .=-t....L JU.j ,;-c::; .A-.~ . G~ l"1'1 I' ,---- I r:>...'-"'t<~::I,.#u... L ,,-1J) ...... ~r- ---- J' (_ .1,,, .,;,.._..__'\. ~ . . ,:x::.. r. 1- - 1-, '.- ''-'-'- ------- - ~1'-'-''''''''' , r-o--- f .. · - - '?- t'~ j:l "'-.;.;.I:.....~;~ c..'fo:.:._:=. . . . I , I" f~. ..0'\ ~"'- 'l.~:... $:, 1.. ""__ ~'"i ~,.. i'\ <.~~- '-c-:,., .J ~ ~ o'~ , r .. \0 ~ c---r f .... I' l:... .~ . A,\' . v-/I"~ ( ......~~. ,.., -.1.., ~... ...., ,< __ t.:..:..~.'::C....c\...l-~"" FI """'i"- fU-..... (,- r '-."... -,~""'_:- ._ 'L' f':'~'''' ;...."->.. . J. "",,-,-,,~ ~-c'-'-"'"">"" ...-,-....::;; ~ 'f ,~,,) I J, L 1 '0... .." -.lo. " .- - r . ,....c. ~'t.o 6..t.~...<fs."''f'-t,.~ L.... .. -- /.. ''''''"'r-.. , . II ~. d~ .u:-~,..... ~....,..,;\ I 1i-~cJ.--~"", . "-- ~ ,,--,:c..........c.:t... .---,- - , -~. ,r -J ,,,,~,.....,~'1~ .' :~/9 /., 't 'Date ......:. .:......~ ,. J'O. SlgnaNre of reCerrlng Physician 'ar: B: To be completed by consulting Physician, :xamlnation flndL,gs and test results. . , . Aa_. L.'"J ~~ r P-' IV\. c~l ~~.. ~ (Cont, on reverse sIde) /"Mit 44\ , Inmate IdentifIcation : BC61 0,0,8, 1- /~ -u. (.. SSN /7;;. s~ -/7VS' Inst, No, I)-~ '-!l./ oJ 7 Name ~lJl.. CA.~ '. COM~IONWEALTH OF PENNSYLVANIA BUREAU OF CORRECTION CONSULTATION RECORD 1.. ,,_ ~ :{:~':(;:~.'e~1.Y('f,"H'lt:~_ '. .1 \~1' ... ''''1'''''~'''''''J':ri~4l'1~,'''; ~i ".1 ... ,;.1;.;""'/; C') ....<1.1 """-"'-'~'I""'>lT"f":'M~'i'1i~~W~'.!)'J/'!;:'..,..w H _ . ---'.- ,.-'- .~-. . o '*'.-,-... .~.,-- l . . . . , , '-~, MUNCY VALLEY HOS PHYSICAL THER PROGRESS NO Clara Clark - 192-56-1945 965370 O/P 12-03-93 Diagnosis. Chronic SI dysfunction. arief aiatory. The patient reports ahe had no previoue hiatory of low back.pain until fall in Auquat 1993 while getting out of the ahower at state correctional Institution of Muncy. She It&tes that day they had her aent to Muncy Valley Hospital for x-rays which were negative and initially she complained of pain in her low back and the back of her head which she hit when ahe fell. She atates her low back pain haa progressed since her fall, and she is now experiencing parestheaiaa and a dull ache into her left leg periodically throughout the'day. She also fells her left leg is much weaker. She complains of pain with flexion and rotation activities. she statea Dr. Hartz has had her on several different medications with which there has been no significant change, and she has also had an injection to that area with no aignificant change in symptoms. The symptoms in her left leg are intermittent and always ramain above the knee. , She states she does feel a little bit better while having moist heat on in the shower, but no significant change. Hed1catioa: She has been on Parafon Forte and states she has a small allergy to Oemerol. social aistory. The patient is an inmate at the State Correctional Institution ~f Muncy, . , S: Refer to brief history. 0: The patient ambulates into the physical Therapy Department in no apparent distress, There is no antalgia noted. The left lower extremity is mildly externally rotated with ambulat!on. ID!J1ls BQHL Flexion _ limited 50' with pulling in the left low back reqion and deviation to the right _ limited 50' with centralized low back pain which travels to the left anterior thiqh Left side bendinq - within normal limits and pain free Right side bendinq - limited 75' with pulling in the left SI and low back reqion Manual HUBcle Testina: ~ Quadriceps 4+ Tibialis anterior 4+ Extensor hallucis longus 4+ Peroneus lonqus and brevis 4+ ~ Tendon Reflexes. +2 and symmetrical bilateral and symmetrical bilateral patellar tendons. Laseaue ~ positive on the left and is not enhanced with cervical flexion. Extension ~ 5 .- 5. 5 5 Achilles, and +1 ~ 1l--1"'/;7 PT 1/32 09/88 FORM NO. 709 . 004 , '. I \ V . . .' MUNCY VALLEY HOSPITAL PHYSICAL THERAPY PROGRESS NOTES Clara Clark~ 192-56-1945 965370 O/P 12-03-93 Fabre'e ~ Poeitive bilaterally tor pain into the lett low back region, iI Comoreeeion AnQ Oietraction. Both'poeitive tor pain in the lett low back region. poeture. Lett ASIS, PSIS, and iliac creet appear to be elightly elevated in etanding, Leg length appeare to be equal in eupine and long eitting, but ie truly hard to aeeeee eecondary to the patient'e. anxiety with pain and muecle guarding with motion, paloationl There iea"eiqnificant amount of tenderneee noted along the lower thoracic and lumbar paraepinal mueculature along with epaem. =here ie aleo eignificant tenderneee along the euperior aepect of the left SI joint. There ie no significant left buttock tenderneee noted. Treatment Given. The patient received ice timee 20 minutee along with iontophoreeie ueing 1,0 cc. lidocaine hydrochloride and 1.0 cc. dexamethaeone phoephate delivered poeitively for 20 and negatively for 40 milliamp per minute. The patient was then instructed in a home etretching program coneieting of piritormie, eingle knee to cheet, , hL~etring etretch, and wall lean. Theee are all to be performed timee 10 repetitione t,i.d, Al The patient ie a 27-year-old female, who reporte to phyeical therapy after a fall in Auguet, complaining of low back pain and ehowing all the eigne of a poeeible SI dye function. I feel ehe will benefit from modalitiee to decreaee her pain and progress flexibility to an independent home program as the patient is able to tolerate, The patient is a good rehabilitation candidate. Goals: . . 1. Full, pain free trunk range of motion. 2, Negative Fabre's and SI compression/distraction tests. 3. Independent home program. Treatment Freauencv. 6-8 treatment eessions. Patient Q2All To become pain free with activity again. PI Will see patient two times weekly for approx~~ately 3-4 weeks tor modalitiee and home program. The patient may aleo need eome gentle mobilizatione to correct the poeeible upelip of the left ilium. Deb Alexander, PT, ATC OA IClb 0: 12-03-93 T: 12-04-93 tk c., attA,t1r.tp-:r~ cc: Leo Hartz, K,D, PT # 32 09/88 FORM NO, 709 . 004 " PT 1132 09/88 , . ."']UNCY VALLEY HOSPITAL PHYSICAL THERAPY PROGRESS NOTES Clara Clark - 192-56-1945 965370 o/p 02-03-94 Di~gnosi.: Chronic SI joint dysfunction. 0: The patient was seen on 12-13-93 for initial evaluation and follow-up treatment on 12-22-93. No further treatment sessions have been scheduled through the State'correctional Institution of Muncy following that time: Since there has been no contact from,the institution regarding continuation/discontinuation of the same, and secondary to prescription for therapy being greater than 30 days old, the patient is discharged from our services. A: Unable to assess attainment of goals as discharge was at last treatment session. Please refer to objective assessment from last progress note of 12-22-93. not anticipa,ted findings and i': Dismiss from our services for reasons stated above. if appropriate at a later time. Please reconsult Thank you for this referral. 4Ctr j*. - ",r,- . to,.,) u.~., !c~ e L. Dg en, PT v:.O:db 0: 02-03-94 T: 02-06-94 " cc: State Correctional Institution of Muncy ..r \ t ...:, ,........ " '.. -",:-1,..' ",", , . of" "a " . '" ~.,~ .' ...... ....... " I~~.' Of ,L.....,' . ~~; \ ',' ( .' I'-' ..... . . \... .. '.'-" .'. '-,,,,I": ". " -, i-... ! .." ... 0'" \-0. , '.., "~I::;;' _.1 ......:,) ...<:('y " "';;;""\' .~. .....~ .. FORM NO, 709 . 004 - --~, . KllHcr VALLft' IIOSPIDL PB1'SIOL 'rBBllAPr DISCBlIIlGB 5UIIDRl' carla Clark - 192-56-1945 965370 O/P 06-22-94 o. The patient was lsst seen in the Physical Therapy Department on 03-29-94. At that t1me, a note was sent with the guards to take back to the State Correctional Institution of Muncy stating that we would like to .ee the patient weekly time. four weak.. The patient has not raturned or been acheduled by the State COrrectional Institution of . Muncy. - . P. Discharge patient at this time. N' ~'T7 ~...u....a /TI,. Matt Andrews, PT llA. db D. 06-22-94 T: 06-23-94 cc. State Correctional Institution of Muncy '. .. , . 'rf~ .. . _ t> ':(~:>'l ~ft.t~~;1~~~"~~~~~~.rr;,,<:~,~\h:.1 .. I. . <' . \.., . "~;'%"~!I~.~ff!\,.... o :; :.;;~~;,_,~',;:" "'" ;>;,:\;~~>\):'~\;> \i,i~( ~;;:.~:~ !,:\,*:;',;_J,~" '''<l.1" ,..--" " , '-<,~ !-,,",l;;':\ ,;.-.;,,-;;,_,,':,,J,',,j;:?j,1j, . ~ -"-...... .".-- l . NAME C//tt..LA C-I..;4 <....e- PHONE NUMBER .~ I ADDRESS c:.....~b.-t-.t../ ~li - SHEET NUMBER !"""':'-'J DATE I PROBLEMS ,..INDINGS IS - Sub,ecllwt: 0 - OblKlrvel I TESTS ORDERED andIOI PLANNED INum**, .net hi D.lCflfthonl ~h,"/~ ...J___ N.fI ~~~t' R,rm ~.".a... ~ - I , t."./., 0 .,. 7<!/);" , - an-, .,,4- ~ 1 ~ 1ZhY7 4/~/l..j) Nt'{r '-,'~ C....... g- - V77 ~-..... ~ 1::..'1 "" ,/: J" 14-10 :r />>,;1_ - C ./ ,I' '.- .,. , /L. A, v , . <;:/~(, J - "Jr'. ~. 'L ..,,~"', ~....... , I .. .,... .L I \~.. h.1 ."'l ,p, /L ''-~ I - - -''''~.~ .. I ,,/ {,.., I -.}- ,....l- I , IJ..- HI/A ..... I , ,j I ;/ ..../ J?~. f h'J.......~' t!' ,.c::.-_ .-d- ." ,~ J I '7.-:r- ,J'~ .~....~~ - :;> " r _' - J ~"...., 11 ,.,/~ '" ~ /~,-(/ '-L.. ~~ ~, " .~~ I ,,2 .'/~ IL/~ ,," . ./ /~;~ A...- .iZ'I P'.~.,,~~ c: _,..~ . v .4/ " /d. ' '" 01' -t./ ~ C " ~ .-...-~ ) ITI .c.... ,~ J c.J ...........-, ';"'/{J 10 ~ c.--........_____._........... '" 7'10 :"'l ,ere.. " ,A,J- ,c. ~.:....._... ~.I-. .r-J' .,tll';-/~ '2,..1 ,f' J_ ;:., ~_\ I/C,,;....... ,--'::.....j .;;:- :J. , "'1..:~' j :: '- 5. ~ : ' CJl.._:t....;I""\." u,~, I .:.--- ~~ , ,L' .. " . p' ..(~... ,. . ;:. i I/~ I ",."l. ',/, ....,...."'";,.. .~'.L ;-" -";";'-."1..). I -, r.... ::';"1, .' 'v.,.'.,. - ..,,' ,,' . '- .;;j! 7' " ' 0: " , --....., T''',;.:,.'}.. -r" " :"A _.' I"'.,) ... .. ,'" " -. , :.~ ,.1,' ~ '~'/'\ll ,..c ~ ../ ";,..,,-~r 'no. - '.~' ,.!\: ~.,.., ; , , It1 I., ,~.,' " I '...u:L.a ~ ";,, ,..) ......, ,.., f'[- I 1, ..,r.'" . I.....'. - I - ~..,,'" " "- .~<. .'.:<:' "'u. OJ {'.fA :, ':'f. - rj , _'/,f!:.,J . ..:., ~ .~ , '" .r- ". "........... '. 'J ..;" ..' .~,~ ~ ~'I'~ ;.4 ';J ,"'}- -;..,... ',p>- ~,\ ,"./ >~.\ '~~U=>"'J7, "'L." .1.t_J" .J "'f ,il" ,'.'1.': '..... , . , " -.. .......~:..I .....,.' '.. :"'<. <-J-.r, .Ir ,.. .'l,U*.. (ll.r;:t"...... '- "=1';....,:,,- " '+1." /.". " -, ~ , ''\'".L''''' I " .' '~. I. . . 1 ' -r- '., " ;j.,' I ~- . ....- I,..:. J:. . r,'1 "/ ,?,'''''.- :"'I-'?,... I.r .'':...-1 " _ . , ,- I............. - ("";p ..." P.'l~ t ,.... , -. ",-::.,\!\ -- ,,' ., .\ '0/ :(1..' '1 ..', , (. '.", ~ ''':''.;- . ~.....",'. , .:- . .. - .. . . ~.(; - '. .. .- . -*,,-:- " ;--, ......, . "::.... '. ."-.. .. " (.'- ( - ," . ~' ......-71 "' ." .- I~ ~~ - . . .. .-. .' .-' . -:-...... u.:;..;... ....... - .":-~ /, ".' l ("o~ , .1 .' y;- '....--'3< .u ..-.:.}'..... . , " . . , .\.. i.o -';.. ~.. ':".:J . , . '- -r . '. '.' . PROGRESS NOTES '0"1I1I04a CO,,"W'LI. .".T..... I""C~ c.....II~...IQN. 'WNOt. ~A.'~E (I J?tr./; (!11-'1(II~ PHONE NUMBEA /C ) ADDRESS SHEET NUMBEA 0) DATE I PADBLEMS fiNDINGS IS - SLb,.ctIW; 0 - ObjeCtlvtl T_DIRID _II' PLANNID INumbt>t M\d Bnef DncrlDtionl -J " /:l . .... - i/ y ~ {( ~C7c ,.. (/ cs-- ,-<J ""'. .- . /-r 'I - VA......... r 'r . k':t'/- ~ -' ~- ~,,- ~ /' . ".'-f." I .., u.o "".... G/l-,N'-' .-( '/ V'I-" ..... ~ /l.o n,- / 'L- A ...J ~ - /r ... I .e Fir ",. J I :4>"", ../~ - ' t't:' ~'-I 'e: 1'------- ~ "'I:: , - I .' " I ,,'7.. ,. .- ; . '/1 ""Io~........... -,/ It/' ... /!. . . ~ L. - ...- ,. ~..' /,,- - ". #" ,/ r .-- .-- --- "./ i I " ../ I 1 Co. /_ Ii J' /, /1 " I ,o''' ... l it I (t; ~-.....- I I . . ./J , /./......._ ,-.J>-- I C/....-r - :....- / , I -(1;1' ,. / ~T I i ~, " _"- I , I /,M../ (j.... " ,,~ A" .... /7 ~ , / '" ..:,.-v ~:- ".h .,... /1- -.' I IV , " ;- 7~~ , - ~ / -/ I t C/ 1,./ /'/H'V'J'-' ~ - 'if t<.~: ~:J- '- ~'A.o _ t.i_d~ } :: d.:. , Q ;::....- ..-,'" .. ).fJ /'l,.t'! h. .",x ,,1':: JJo I. JI"'\ , . .J-""-",-:'. ~ "/r., , 'A. i 01'.f......:.w . {.Ii I /.1 I,....: ~ (I" /&1 . u ---- I ,r,.. t:.A;U p/-f'I-t.., 'ilr .. /.., /.. J IJI-f-'-" I /'Vwry ;. I . , I ~-lA; , / I" './ . , I //' " I' I :..,..,.".,.' ....-:;,Z"'..-t-f-....,. l'"' t {/...... '~- . , /.10:. hl.:.~"'" ,.- .' I;"'~. , I ~'.",",- ^ r. C~._... I , }:;~ "l_ " .:""'-;.-, I . .,_.. "'~h'_ I " - , /----- , . :.../. . "' ,.".". . " ., , H' ._. I I I I I fI' U.I yo- ~ I ,,1(7 4~ I' OAT! 'NT/BSA CPT C9Dl! I 1/ 17 (r~ , >'2- 30r , I I I ,- - ,- i ,) , 0,/,/.-:, \, ... "v...,- ,I. _'" ~'"- /i: .,. ~ ~ '( f-A r- rr--- :::;.- /V)-~, -'" ~ ,rI- ~ ~;-/~_#.;-' - ,~.Q<.-- ~~- tr1-~ -<0' 7 ~ ~ .pUf,~ /e~: ~/ - ~........e..--'-- -.-. ~-}---- ~~. _r~~" __ ~r/~I ....71 1 ~.h~ /' ~~ , r;::; tf"rvy r /y-/' ~~7 f7'u~ ~:q'v ~ ~~ 4/' _, __ ..-:::l ,~.~ ~:-._~. -~. - - ,- h_ ----n-~r-:v--.. /i~)'7 \ /....7vl- ;-- ~ ..--- Vtr- I /'1'/'1---- ~7 ....vo ~~- ,- - a----- ;t- ')/~~~ - I , -, I ---.'1 I /i,~ ,'~ I!-,::F'-'- , /,--r-' ......---- &"""')o"~ /-.~ - I i .n................~..~..Il)..._.... "......._...... 1 '.. .....~........___....._~-.._....., ~...........__.fII_2 _, s...~ .......oAtlMN5TlAflOH..'" -........--................ .. --"'--~ ~it_J._' '''~__cn,,>pe.........talitprocMtandh ,...,.,......ahtlraryu~ I'IIiaIM lI:lor-MhaM'Wf....CI'I.tatftblur. \J5,(1N "fGNANCY ~.......~.........._......._ACl..........CWI__' ...._..........--........ ft'two.......-,.".....ACCl.ft\........ .-.... _....... s... -.INN>>. ...~......... """'-" CoNnrexILooo PRIssuu IN MOirf PAmm_IlAJsI7HE DosE. AccuPRIL QUmonlHCltablels lO,20.40mg "'- _ bAIl WM'O"f rJ Y I"'Cflborog ~ tIftCbed ~~ ........'... _c-. o\larIot......,........01950 PO.l03.IAo909'l..'lO'14, ..10026 ~ ,".. W:lrNt.l.onOtn C~ LITHO IN CANADA Pallenl Name Dale/Diagnosis , ." . ., .,},. ~. ~,( (.. I," --- ,,.. . Page (Y PlANS 8< Il Ilinh Dale HISTORY'" PHYSICAL (Subjecllve and Objecllve) '. :' /D " , ~ .. I I " '* --:z.- ~ . ;-v' "" . t..-z.,_ ?7:- - '-'-- " 1 ~ .h.-t:.-- 2.--z..~. ~ c:::.e.- ".,> aaritin~ !J.'!9 (fnrntRrlinA) New. bJ.d. CIarltln:D ~~~:-,__",wr:t.. lnVl'! "-"~ ......-.',..~ lJaracnl Name ,,,,\ : . ~7' _A: ~, .l . 11.',(1_ Dlrlh 0.10 .~ P.gc _ 10 0.lclDlagno5i5 a!;1 {O'<' HISTORY & PHYSICAL (Subjcclivo .nd Objccllvcl .... ~~ ,- . , ~ . ,/ ,.. I..JI- ,-- .'1":\ "..... I w /' "_ /I /: .~(... _,/ '"' I." <.01. .~' ...." Claritin. New,/Wi CIarltln:O "'l~..~"'."'~" (ovc~ " . Pip PtJ\NS .. a , , - . ,t-, .,........, , ...." " "JI:.. ;/ '.:',c ,- v,,/?- C,. S . .0. " ~o 3~It1d Clarltln~ __11__........1"_....\ ,n', l]'llnl3.~ Nttw, bJ.d. ClilrItJn:D .....1.._......... 08L9~8r019 ~O:(l (,wcr~ 3661/8':/ZO ~ ..~-:~ --- -- ......-~.- dt!~ .) .,.lcal HIIllI D,1cID1a II I #' r' - .. '. - .-- - ;....~ a-<-o( ~""d Oarltln.. 1l'!!l(~t::Irl;nP) 'B,'~ 13'll!13d :D ....I~.__... till. OeLq~8rOlq ~O:(I (ow,) %&1/8:/:0 ~ ", (~ cb~ '\ . "\ o III ',' .' , , -L- . ..~; ~., . ~ . I J . , .,..... '" ~Q~ .' r ... ........... ~ :. " ~"",,," " ....~ ~Jr.:H'.. ollJ..~ ;11 ..... . ....,). " ......~..a.... . .'OI!,. J~i,~,"oo:r..' oljof~'",. (I' 4-0\.; I ,t 1,' i.'';'-'' ": ,,' -.~. . '~"";", . ': " .' .' ~ .f . C1ar1tln.. ~..II^"""",""",.J,'...^' ,]3.', 13']1 ~ 13.l ~ bJ.d. CIarItkI~D ......-.......- 08,g~8rO,g ~O:(' '. ' ,l ..; ',. '.' :f 'j '::...J';" I,"J Ii ." .I', , ' i ~. . ,," o ,C L. , .1.... 1_' ; , " , ',," :,' '.i ,I t.' . ~ "p'. , I , , I ~ ."" J:', ..i' -I.'l. ~. " , . - ,~ j I : .! . : :1 ~. j ! t :'t. " ,', 1'"' ':", I "'j. ~j I:. , " , .. .: 'i. " .." ;':1" "., .' " r'l: ;, (: /~ c; u~.r<..;'- i SECTION II ITa tHI complst!d by physician) I The information on this form will be used by the CAO to make an assessment of your pa;lent's qualification for (1) General Assistance. Chronically Needy status. on the basis of physical or mantal incapacity for substantial gainful employmant (substantial gainful employment is any work which your patient can perform at least 30 houl1 wlltlkly for payor profit,), or (2\ for exemption from public assistance work requirements becaul8 of a physical or mental condition, Please complate this sactlon basad on your BYaluatlon of the patient's complalntlln Sactlon I, PHYSICAUMENTAL CAPACITY: Ch.ck 1 ) tho molt approprl.t. block In th.lln below th.t refl.cu your opinion of thl pllllnt's c.pac, to work, Pi.... Natl: I narmtl prtQnlncy should no; bl rlgardld U In Incapacl;." IChock 1""'-1 only ani,) 1,0 2.0 CalMCi;., Unllmllld, Phy.lcll/Mlntal CapaclIV II adlqUl1I to ..Ik Ind mllnttln full'llml gllnful Imploymlnt in . nom work Invlronmlnt with narmll work schedul.., CaPKl;., Unlimited wllh AccommodatiON, Hlndlcapped or dl.odvontogod by I .lrlaul chronic IIlnlll or condition, t not to thl point thlt preelud.. full.lIml gllnful Implaymant If rl.anabll accommadltlonl Ire midi, RI.anlbll lCCa modatlan. may Includl: Itructurtl modlllcallonl, modlflld work Schldul.., acquisition or modlllcallan of IQulpmlnt dlVICII, pravillanl for rtodln or intlrorttln, jab ,"structUrlng and athlr .Imll.....ctlan.. or thl nled for drug mllntlnln'" Chock thl fOllowing blockl.1 which IIlply: D Phy.lcal Limltltlan. 0 Mlntll Llmltltlonl D Hlllth SUltllnlng Medication Needl' 3, 0 CaplOl;., Llmitld, Hu I chronic or .cutl phy.lcaI or m.ntal condition which rlStricu but do.. not prohibit .mploym. If work II 30 haun or I... I week, Chock thl fOllowing blockld which IPply: D PhYllcal Llmilltlan. D M.n;11 Limll3tloN D Hlllth SUltlinlng Medication Needl 4,~ Tlmporarily IncaplOitllad, Currently InclPlc';lted dUI 10 I Ilmparory condition or .. a rllult of an inlury or an acu candlllan and thl Incaplci;., tlmporlrlly preclud.. am pia mint Thl IImparlry InclllaclIV Is axpected 10 I.t until ':li' ",,- . I AT 1.1 '1IISIamlnt of this condition nladed after thl abavI dlte?' 'Sa'YIS 0 No . 5, 0 IncaplOltlled, Profoundly limiting phy.lcal or mental condition ~onontlY preclud.. any form of Imploym.nt. COMMENTS: If block 2, 3. 4 or 5 is checked, substantiate your assessment of physical or mental incapacity by providing information regarding: t1I DIAGNOSIS (Prlmlry and SlCCndary) AND MEDICATIO~S RELATED TO EACH DIAGNOSIS. u. . .' Prlmlry: "P~'lG;\j~I\l~( Medications: ('ou("l..ll- ,j '" p~ "a/'6. Sacondary: L.- 5 .$T1~\1\J Medications:. tJ ~ 121 FUNCTIONAL LIMITATIONS: f'! 0 tI W9 ,"lei ) p-'\..~~ .:5f;u'tvl.;/';::f ~~r1Ar{ Sut:Ci:.CJ v "'L 13) Hu the patllnt eVlr racelvad 3D con;lnuous dayl of InPltllnt Clre In I faclll;., Ihospltll or psychiatric unill for thl mentally ill or mentally retarded? ~ o V.. DNa (_U known If VII, pll.1 identify facillIV and dltl. Fmm To DATE PACIL.ITV PREPARED BY MEDICAL. PROVIDER ADDRESS :,'.:'; tEANC. .:. ). -,,~.....,.._.._.. ~...- i.IN'.'ICOD, P,\"' i~~~"i'~~ (tUG) JCO.ll-:a ?j ~'::ATU-:::::: C/ I ? c, / q 1.../ I OATE ' PA 635 . 3/84 ..,--.- La.., '\,L~L (:.J..L LiC ! SECTION II (To bII camp/tired by physician) I The :nformation on this form will be used by the CAO to make an assessment of your patient's quallfic3tion'for 11) General Assistance. Chronically Needy status. on the basis of physical or mental incapacity for substantial ]ainful ~mployment (substantial gainful employment is any work which your patient can parform at least 30 houl1 weekly filr payor profit.), or (21 for exemption from pUblic auistance work requirements because of a physical or mental condition, Please complete this section based on your evaluation of the patient's complaintlln Section I, PHVSICAL/MENTAL CAPACITV: Check I I thl man Ipproprllle black in tho lilt below thl; rlfleeu your opInion of tho pltlOnt', ~apooil to work, PIIIII Nato: I normal pregnlncy should no; bl reglrded as In Incapoolty, IChock (., only anl,l I,D 2.D Capoolty Unllml18d, Physical/Montll Capoolty is adequlte to sNk and mllntlln lull.tlmo gllnlul employment in I no",. work envlranmlnt with narmll work schedullS, Capacity Unlimited with Ilccammadltlans, HlndlcaPllld or dlslldvanttQtd by I senaus chronic i1lnlSs or candlllan, b no; to thl paint Ihal preCludes lull.tlmo gainlul amplaymen; if relSanablo accammadallons Ire mlde, Reasanlble aceo, madltlans may include: nruCNrl1 madlflcaaans, madlflod work schodullS, ICQUlsltlan or madlflcaaan of equipmen; davic:os, proVisions far reeda.. or interpretl/I, jab restructUring and ath., slmillr'3Ctians, or thl nlld far drug maintenanet Check the fOllowing blacklsl which apply: D Physical Limitations 0 Mentel Limitations 0 Health Sunalnlng Mldicatian Nttdt< 3. 0 Capoo!ly Umlted' Has a chronic or ocutl physical or mental condition wnlch rlStrieu but daIS not prohibit emolavmer If work is 30 haun or less a week, Chock the fallOWing black(sl which apply: ~. D Physical Limltttlans D Mental Limita;lons D Health Sunainlng Mealcation Need.. ~, c:::::r Temparanly Incapacitated. Currently incepaciteted due 10 a temparery condition or as I result of an injury or .n aeu , condition and tho incaplclty temparanly precludes emplay?"n;, l f!!'" The lamparlry IncaplClty is expected 10 lISt until h I- ~ _ q ~ IDA r Is I rewessment of this candltlon needed 1ft., the abave date? ~es 0 No 5. 0 Incopacimtd. Profoundly limiting physical or mentll condition which permanently precludes Iny farm of employment. COMMENTS: If block 2, 3, 40r 5 il checked, substantiate your assessment of physical or mentel incapacity by providing information regarding: (t) DIAGNOSIS (Primary and StCIlndaryl ANO MEDICATIONS RELATED TO EACH DIAGNOSIS, I Pnmary: P.~ Medications: I Secandlry: L-5 S'l7\.P-I-N Medlcltlans: I I '21 FUNCTIONAL LIMITATIONS: . ~.;; (18N2. <... FJ"Y , ." :.rto >- ~~ 1/.c ) . -- ~f;(..~CI <__~vl..""4 -' /-- 1/ . i/ ~ ~pJ- 131 Has the pltiem aver rtlCtlved 30 continuous dlYs of Inplaem Care in a looillty Ihospital or plychlltrio unlU far the mentllly ill or mentllly retarded? ~ ' o Ves DNa --r-".nawn If Ves, pie_Identify lacillty and dlte, Fmm To DATE FACILITY PREPARED BV MIDICAL PROVIDER 1541 Chlct.eslllr Avenue , , f~.(610) 465-1176 ,-: ADDRESS Z, 17~ /q \" I DATe I SIGNATURE AND TITLE PA 835. J/S4 .. <' '" -_.... -.--.' I. \' ....".........,. . ,~!~,~,>,y'!:L9&:~ ,J".~, ..~," "'.' '0,/ _"'~~. ,"-'~.. ,:~,;.~;\l~'~%,!,.i~""$."~I~~""~i't'!<:"",,~1 u 'oJ .-..---- r ,,-' . . 1ft t _;.1[.\, J.. " 1_- . CROZER (R01.1R.nIUTtJt \IEDIC.\L [E'fER l'PLAND P..' I~ll~ William H. a,"". M.D. C/IlIltINtI DEPARTMENT OF RADIOLOGY DII~no'llc RIdIoIoVY CU.ZIOO Kl Woona Kim. M.D. JOllpl'1 R. Stock, M.D. Blrblt. A. McCAn,l1y, M,o. John A, BoneYlll. M,D. RIChIId N. T..",. M.D. Stefan M. Skallna, M.O Howllll p, R_belll, M,O, Nool L MItnOm, 0,0, .lamel W. HUlted. M.D. CArne L. Kr.. e. M,D. RldlaUon Oncolo9Y ..'.Z'CO G_ E,IoAcC.""", ,",,0, 51_ A, AmQO, f,A,O, UncoU1 K. PIO. M.D. NAME:, R" . '.L ' ;L..1,.... ..".,. ... ::3 ~. :'::JQ ..- ... .--..-- ......~~I :~ AGE OR DOB: ..I.. ' , ,.' ~ ~ ~e ................. ...... ~ "1';:'.J ,~'1 PT, BILLING NO,: 3ll~.:.:.::~~11 LOCATION: ':"/C: :-,- '. . SOCIAL SECURITY NO,: .'):~~~~ :...:; DISCHARGE OA TE: ~CI1i'~Ej :..:.:; ~ I';.. .... -:".1 :C::..tl ..,::1S~3.;.,:;::.:.L ;r: ::11:: .:7~ : "'. ....-.... 117:=1:":':'" "'" . .. ... .It. ! ~ !" :oit'...;.! -.... . ;.~ ~ '!:"", . ... ':' . ::'.. .. .. ;\,:i of J!'~ : ...... ~ ,~'".. ;'::1:1::'-: 1~",.,:' .:ml.ilJ" :!.. .:~:.: ,:~:.i, ~';l:'r..lr ~V.~. ;1) '"at! ,,~l'\ l~~-!Ti~';.n~:; .ilo! "ole Joa.':JS :~'H" _Z "".oJ ;;'llr.:-'6't. ,a,1:crt!l. '11) ;)r'~I' J~Ut2t~$ ."''''1 1"....-\1:30.= "i'i.:': /' '.' t :....~!'. '.;nt~,- ~~ 'aI''' j~.....:I'''4': .n ~!'C\l" . ~l' :J,~t..ir' $,'". 4t ~.I"td ,:..3-..l ~'..-!.. :ner"i . = '0 t'r':en';~ j'; 11.iC. "i',r"lil":.l,:n. -"<I '!Urli ~:r1m'~a lri )d~~"~. !;,~ .~5U&l'=2~ 'S5~~US ~~r~c~ur~~ lri ;~r~~~r~~u'!. ....1:'; "':h" ....1-~ : .,'J11 '"t-er' .; 'CO ttJ' .h!nc.t ,).; 11:iC '~"I'''''' ~t":~h -?'\'U"i 'il'l :t!' t I'!::'" 1t1",'a.l :3!''':,'"\' '1i:\'. :I~ ~~. ..t~'i '1~l..;,"~.. -....~.~.::, :i:-! ';'~:;;.~. ,--------- ----_..__...~ ~":' ~:'ld .~-it '~",,!::. ~~~:': J 'I,} ,'.::an,:t ',;.; :'JC '~r~.::.~'~;" ~q&ll\, ~i't'!r! .:ta:' 11! J .1.~a. t : Jr.-:-:'.-l; ~:. iC. ':IJ .;e. :h~ "l~I;_-'11 ..::.....I~:):i, !.I"'l ;i.ta:n.... -------- ; ~ ,:;~;;"IE ;/RE=G~. I.;). ,', ~;<: ~,..a Jf S~ot!m~r :~. L'?O~ \' , ORDERING PHVSICIAN: TEANO :10 OHN ,~41 ~~I:~,3T,~ ~V :_!NWCCD =-:. ~"(o: 7:;:';NO '1D OAt~ /ivv~ :~.J 1 -::41 C:4~S;ER ,~v _::Iv.~:: :..;. :0:'00: ....", . CENTER OF DELAWARE COUNTY 475 KEDRON AVENUE, FOLSOM, PA 19033 610.237-6674 DIrector STEFAN M. SKAUNA, M,D. CLAlUt, CARLA 192-56-1945 DR. TBANO Oata:9/1/95 Statua: OP CO!C J50BILB Name: S~S. No.: Referring Phyalclan: Mal OP THE LUMBAR SPINE I HISTORY, Status post injury 1 year ago, with left leg and low back pain. IMPRESSION, Normal examination. COMMENTS I MR examination of the lumbar spine was performed including sagittal TR600/12, sagittal TR5000/119, axial TR600/9 and axial TR5000/119 images without contrast. The lumbar vertebral bodies are anatomically aligned. The disc spaces appear normal. There is no evidence of focal disc herniation, central spinal or foraminal stenosis. The conus is normal in size, shape and position, There are no findings to suggest focal nerve root encroachment. There is some mild degenerative change of the facet joints in the lower lumbar spine. J~ ~~ BIEHLE, JR.. M.D. JP"S. I qmc DT: 9/6/95 .(' Mercy Catholic Medical Center THEIlE"" c. POWER. 0.0, CIt.'rrMn MARK E. SCO~ 0.0. JAMES R. MESHAM. M.D. Crozer Cheater Medical Center WILLIAM H, GREEN. M,O, CINllfMn STEFAN M, SI(AlJNA, M,O, ;a WOONO KIM, M.D. JOHN A BONAVITA M.D. QAIIR'E L KIIESGE. MO, JOHN F. HIEHLE. JR., M.D. Delaware County Memorial Hospital THOMAS'" DlUBERTO, 0,0, CIt./rm.n /rf\rY'\ RANJ,T R, SHAH, M,O, VONG AlOOK (8EN1 KIM. M.D. BEN-Z10N FRIEDMAN, AI.O. . CENTtR a: OI!L4'o1ARE CaJIllTY 475 KEDRON AVENUE. 'OLSOM. PA 11033 .10.:/37.aa74 DIrector STEFAN AI, SKAUNA. AI,D. CLARlt. cJ.lIr.... 192-511-1945 DR, Tu.HO Dlteil./19/96 Statue: OP COlIC JIOI!IILII: Nam.: I.S.No.: R.f.rrlna Phyllclln: KIll 0. '!'lIB CEllVYt"AT. sPIn 1/1919111 RXSTOay! MVA 1 year ago, rule out HNP. YKPU!UIYOH f Unremarkable MRI of the cervical spine. CI'\MII1N'I'g . Magnetic resonance imaging of ehe cervical spine was performed utilizing ehin slice technique in the sagietal and axial planes, The spinal cord is normal in caliber and singal intensity, There is no evidence or disc herniation, spinal stenosis or neural roraminal encroachment, The vertebral bodies exhibit normal stature and signal ineensity, I' 'm II\. JOBlfA. IONAVITA, 11.0. JAJl.qtnc OT: 1/23/96 ""rey Clthollc Medlcll Cent.. _104 G.1'OWI1l. 0.0. -- ....~ L ""'FT. DO. JAMtU ",_I/o. CrDII' Chlm, Mldlcl' Clllt... "'UWlH tMUN. "b. - If'UANtI. """"""..c. lO""ONIl_..D ,/0......, _V1TA...,O CAM,. ..1OlE1llf. AID JOHN' HtrHIZ. A, AJ.D. 1I31'1 13>JI ft 13d DIl.we,. County ".mo.rlal Ho.lpllll 1HOMA4 A OlJ8tll1'O. 0 0 -- ItAIUIT If. SHAH" W D rDND 1olOOI( INNI I/IAI, .. 0. 'fN.lID'IFIlf_,"D SEP 15 '95 13:12 FROM MRI CENTER OF DELCO PAGE,OOI '. MRI PROFESSIONALS, INC. 4'75 I<edron Avenue. Folsom. PA 19033 Office: (610) 7.3'7-6674 Billing Service: (610) 690-4755 PATIENT REGISTRATION INFORMATION . .r Datw of Se~: FItat Name: ~ ~, Middle lnltla~ t SocIal Security: / 9 c2 -.s-~ -/9 fL,j' laIt Name: Sex: +" DOB: :;~ AlIl8 COde: 0 D Telephone No,: Sla\us: 0 P Hospital: Relerrlng PhYS~lan::iLl -:l"t. I ~ physlelan Performing Study: p. i./;" h /t"_ Diagnosis: -I- proa!dure Code: 7021 $'1 Description 01 servictl: t.p};f.::r i ~ ~:u ~ .0 F~~.f", ~otal; Amounl: DIscount Balanoo: ~ h Stala: ~ ZIp Code: t,fr<f-ol9'..J R / t:t () /.. 7 Rlglstratlon No,: phone No,: Charge: Paid: Due: MEDICAL INSURANCE INFORMATION: PA Blue Shield: I ) Primary: Oul 01 Slate: I) Primary: 1.0, No,/Agreernenl No,: Subscriber: { J Secondary: ( 1 Secondary: Group No.: ReI. to Patienl at, Date Aulhorlzalion No,: Medicare: I ) Primary: Subscriber: Rei, to Patlant 1 Seoondary: Ell, Dale PA Medical Assistance {'/J ReclpienlNo,: CJ:::1/.;v.;,~ ...,7148 Card Issue No.: /'YJ .. TOTRL PRGE.OOl .. CG I. ( ~ --- .,.~ --' -.... j",,tl1ft-'-'":..,,,~~,.;,......,...~.,,,., ,''''''~ 't,J o . . ',0. ';,' '0'~";"'^-''''''';''''':''''''"<' .....iJ .~- -~ '~".-''''.-'-...- DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER 201 Eut 1011\ Street. r, O. BoA 362 . .....rcu. Houk, rA 19061.0362 !'hone: (6tO) &59-9\10 Fw (610)859.9121 PHYSICAL THERAPY INITIAL EV ALUA nON NAME: Carll Clark DATE OF EVALUATION: 11.7.95 AGE: 29 DIAGNOSIS: Lumboslcryl Sprain/Slrain wilh Rldiculopllhy REFERRED BY: Dr, Dan Teano HISTORY: Patient is a 29 year old female with eomplainlS of pain in the lumbar region and pain radiating down the left leg. She stites pain staned when she fell in 1993, X-rays It that time were negative for frlctures, She WIS unable to receive treatment as she was pregnant and had increased pain with the pregnancy, She had an MRl approximately 2 monlh's Igo but docs not know the results, She is referred now for physicallherapy evaluation and treatment. PAIN DESCRIPTION' Pain is Icross the lumbar region and down the left IC8. She has oceanional tingling and numbness in the left Icg, Pain increases with lifting. bending. prolonged sitting or standing. RANGE OF MOTION: TRUNK: Flexion 0.50 Extension 0.10 Sidcbending Left 0.25 SidebendinB Right 0-25 LO 3!l\1d oJ3W 130ltll3d OSL9~Sr019 ~O:El 9661IS:I:U ST'RENOTH: TRUNK' Flexion 3+/5 'Extel\llon 3+/5 Sldebending Left 3+/5 Sidcbcndlng Right 3+/5 SPECIAL TESTS: Straight leg raises positlvc for back pain at 600n thc right and 60 on the left, REFLEXES: Intact SENSA nON: Intact ASSESSMENT: Patient with lumbosacryl ,prain/strain with radiculopathy with pain, limited trunk mobility and strength, and painful functional activitics. GOALS: 1. Decreasc pain in the lumbar region and left leg 2, Increase pain free trunk mobility and strenilh 3, Increase upper and lower body strength 4, Return to full pain free functionaJlctivitles PLAN: 1. Moist heat 2. Ultrasound 3. High volt galvanic stimulation 4. Trunk mobility and Strengthening exercises 5, Progrcss to upper and lower body strcngthening exercises 6, To be seen 3 times weekly for 4 weeks SO 39':1d 03W 130l1113d OSL9!;SrOt9 9b61/S~/ZO . Thank you for referring Carla Cluk to Dynamic Physical Therapy and Rehabilitation Center, U you have any questions, please do not hesitate to calJ me, 1 . lit... . "-1/V /._ f Michael 1. Pino, P.T. MJP/ek , ;.~.! .3 DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER I Phone: 1(610 1859-9110 Fax: (610 859-9211 2011!.ut 10th Street. p, 0, Boll 362 . Marcus Hook. rA 19(6),(1362 11-8-95 Carla C1uk SUBJECTIVE, Pltient Ilottemporuy pain followins YClterday's ICJsion but paillw tred. OBJECTIVE: Treatment: Moist heat with high volt galvanic stimulation to the~umb,ar region for 10 minutes, Ultrasound to the lumbar region at 1. S walls per centimeter squarp fot ;' minutes, ThCfllpeutic exercise consistins or sinsJe knee to cbest, double knee to CbCst.. ,Ilw back rolltions, panial sit ups I , I , ASSESSMENT: Patient 8Cltinstempomy pain relicffrom trcalment. I PLAN: Will continue present program, \ ^-v.Jl-1"' Michacll! Plno, P.T, MJP/ek .'-':::" ::~;'~".' DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER 1l.Jll-95 Phone: (61~8S9-9110 Pill: (61 11159-9221 \ I SUBJECTIVE Patitntslltcs that overall pain hu dec:reucd a1ightly since initiljnB urtmtnt this week, \ OBJECTIW: Treatment; Moist heat with high volt galvanic stimulation \0 thc\ lum~1Ir resion for 20 ,minutes, Ultrasound to the lumbar region at 1, S walts per centimeter squarf for ,I minutes, Therapeutic exercise c:onsisting ohingle knee to chest, double knee to clest. 'ow b&tk rotatioDI, partial sit ups, , \ ASSESSMENT: Overall patient is improved with initiation oflreatmenl. Carll CJuk 2011!utlOth Street. P. 0, Box 362 . Marcus Hook, PA 1906Hl362 PLAN: If pain remains decreased will increase exercise program next 5eWon, \ \ ~p..Jfr' .. "_"06\ I' Pin ' P T lYlIWlaQ. 0,.. MJP/ek 11.15.95 CarJa Clark .:-..... .;~.~:. DYNAMIC PHYSICAL THERAPY & REHABIUTATION CENTER 201 ENtlOd1 Street. p, a Box 362 . Mucus Hook. PA 1\10614362 SUBJECTIVE: Patient reporu the gell good pain rc1icffor the remainder of the y f't"owing treatmCllt IIId thm pain rClU/1lJ the next day. I OBJECTIVE: Treatment: Moist heat with high volt galvanic stimulation to the I~mb.,. region for 20 minutCl, Therapeutic exercise consisting of single knee to chest, double ~ to e,'esl, low back rotations, and paniJl sit up', \ I ASSESSMENT: Paticnt continues to get tcmporuy pain relief. I I PLAN: Will attempt to increue exercise prollf1lm next session. ~!-;Ir MJP/ek CA,c[tl C t. II(.~ Ie. ) ) } ) ) ) ) c.... III The Court of Cocmon Pleas of Cumberland County, ?ennsylvania v 19 ,/ '-/)$'7 ~o. </)- , C orfl, g fc... . f OATH We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States snd the Constitution of this Co~on- wealth and that we will discharge the duties ....~ of our offic~ifidelity. ~1-1 / Cha1r.nan 1/..( Y ~ .)1';( ('~///- , .~.../ -' ~- - - ~- r _ /;::;;Z?/"'. - ..--;;;? . J - (or ...... ...0 . f': ...;. ~ j-' 1.1.1 (' ~ ._. (").,, li'(- cSt. r-.~.~. ~: [i'!'- ~ ~;~ l'_ r.... ~:J <.) 0' U We. th~ undersigned arbitrators, having been duly appointed and sworn affirmedi, lllake tbe following award: (Note: If damages for delay are awarded, they shall be separately stated.) : j '~I AWARD P, -v d (; F 1) t' fe,,, J .\,01 A,'" " 5,.) FA. Ul',," AC,/\i,;,<-,T PLA ..\1 ~cI~ F" <;-1 % Ii" /.>,1"/ '\ fl.... 1- f' L,'\. '''; ~if ,: {, Iv r V.vfl:.'IH, ,.,.: 7 N..!; L I >-e,vc (" t.3 -( c. C'-f:'d So , ~ Ib ~I . , applicable. ) . Arbitrator. dissen~~~t ~ame i: \ /,C:J Chair.nan ,A', r;! rJ7-'/t't"'t't!!t'u____ ...;::~~6 NOTICE OF ENTRY O~' AWARD (~,- ,..,,) /I/:>C/11 UIH I q 7 Date of Hearing: .1:.......... F'- Date of Award: 'tJ.,.. lfow. the :)0' day of ~r\,,'......h,l4:'- ,19.11..... atJ6:'I6, .t!..:t., the above award was entered upon the docket and notice :hereof given by mail to the ?arties or thei: attorneys. Arbitrators' compensation to be paid UpOI1 appeal: roc $ .~qo, ;:;j~"...~.--.:I..I,. ".c_~ c!'. L,-'L" (,1..( "- Prothonotary " ~,h,J,.\ ((, '1l"'f' \ o Deput:, 3y: .---.... Y4l~~/'~!. (d~1j,L SS"i/ 120- '1'~' 'ltd.1o ~, ; I . ( 1..-"......- l., t./ ..J~t. ' .~....,{.. ,_.:J'~L"', ..>k.-;f I ,n..l__''-. 'j ) f' J.......<.(,t..._r~(.....~ JAh.J\(..hA..... ',-..J/U... 5 r ! ::: -- 11 <'J A..:;- . ..,) ~,