Life Underwriting

Name: WOODWORTH, EVA Policy Number:

DOB/Age: 4/19/1965 (57) Scope: 12/6/2021-12/16/2021
Gender: Female Page Count: 16
RP#: 10001348 Provider:
Last Rec. HT/WT: 5’10’’/343lb 13oz Facility: ORTHOPEDICS NORTHEAST
(12/16/2021) Report Date: 8/10/2022
Last Rec. BP: 130/85 (12/16/2021)

Data Lens Overview

Category Keyword Count

Social History tobacco 2

Risks depression 2

diabetes 2

Medications divalproex 2

Social History
tobacco

12/16/2021 Pg. 13 married 56 year old patient. They quit using tobacco products in 2001.

12/6/2021 Pg. 16 married 56 year old female. She quit using tobacco products in 2001.

Risks
depression

12/16/2021 Pg. 12 Abdominal Pain Bleeding, Chest Pain, Convulsions/Seizure, Decreased Motion,
Depression

12/6/2021 Pg. 15 Abdominal Pain, Bleeding, Chest Pain, Convulsions/Seizure, Decreased Motion,
Depression

diabetes

12/16/2021 Pg. 12 DIABETES - TYPE 1 (CURRENTLY ORAL MEDICATION/OFF INSULIN-SINCE

WEIGHT

12/6/2021 Pg. 15 DIABETES - TYPE 1 (CURRENTLY ORAL MEDICATION/OFF INSULIN-SINGE

WEIGHT

Medications
divalproex

12/16/2021 Pg. 12 (amlodipine) * potassium aminobenzoate unspecified unspecified (potassium

aminobenzoate) divalproex unspecified unspecified (divalproex) divalproex
unspecified unspecified (divalproex) divalproex
 12/6/2021 Pg. 15 ' divalproex unspecified unspecified (divalproex) divalproex unspecified unspecified (
divalproex) divalproex unspecified unspecified (divalproex) lisintopril

Vital Signs
Date Height Weight BMI Temp Blood Pressure Pulse Rate SpO2 Pages

12/16/2021 5’10’’ 343lb 13oz 48.81* - 130/85* 98 - 13

12/6/2021 5’10’’ 330lb 46.85* - - - - 16

Medications
Medication Name Dose Last Noted Pages

lisinopril - 12/16/2021 12,15

cholecalciferol - 12/16/2021 12,15

trazodone hcl - 12/16/2021 12,15

desyrel - 12/16/2021 12,15

celebrex - 12/16/2021 12,15

clecoxib - 12/6/2021 15

furosemide - 12/16/2021 12,15

vitamin d - 12/16/2021 12,15

buspirone - 12/16/2021 12,15

glipizide - 12/16/2021 12,15

amlodipine - 12/16/2021 12,15

potassium aminobenzoate - 12/16/2021 12,15

tramadol - 12/6/2021 15

divalproex - 12/16/2021 12,15

lisintopril - 12/6/2021 15

linaclotide - 12/16/2021 12,15

tizanidine - 12/16/2021 12,15

celecoxib - 12/16/2021 12

Social History
Type Status Date Pages

Alcohol No 12/16/2021 13

Smoking No 12/16/2021 13

Family History
Relationship Condition Pages

Grandparent Heart Disease 13

Father Heart Disease 13

Mother Stroke 13
Relationship Condition Pages

Grandparent Cancer 13

Father Cancer 13

Diagnostic Testing/Studies
Date Test/Study Impression Page

12/16/2021 Imaging/Diagnostic Right hip primary osteoarthritis 10

X-ray images Right Hip 3 views of Grade 2 (minimal)
[AP;AP pelvis,Frog Lateral]

Encounter Narratives

Ambulatory/Outpatient - 12/16/2021 Pg. 12

FACILITY: Ortho NorthEast

Provider(s): Jonathan R. Lynch MD

Key Concept(s):

Narrative(s):

(Assessment/Plan) Eva is here today for evaluation of right hip pain. Denies injury. States the pain has been going on for
about 2 years. States the pain is in the groin. Does not radiate. Denies backfradicular symptoms. Examination has pain
with range of motion to the right groin, X-rays taken today demonstrate mild OA, Conservatiwe measures were
discussed. At this time I would recommend the patient attempt to lose some weight to improve her pain. A referral to Dr.
Gerhardtstein for weight loss. She can continue to rest, ice, modify activity, take antiinflammatories as needed. I will see
her back as needed Consultation ordered. ONE test scheduling will contact patient .to assist with scheduling. Eva should
follow-up with me as needed for orthopedic care, and call the ONE office with any questions or concerns.

(History of Present Illness (HPI)) Eva is a 56 year old patient whose main reason for today's visit is pain in the right hip
with giving way which has been present for 2 years. The patient denies an injury. The patient is not on narcotic pain
meds. The patient states that they are having a sharp pain which is rated between 3 to 10 on a scale from 1-10. The pain
occurs all the time. She denies the inability to rise out of bed or from a chair without assistance. She experiences hip
stiffness that limits daily activities, hip pain at night and the need for rest periods when walking due to hip pain. The
patient denies having any other symptoms. Treatments which gave relief include heat. Treatments which sometimes
gave relief include medications:PREDNISONE for as needed. Treatments which did not give relief include joint injections
performed by Elkart. States her pain is in the groin. Does not radiate. Occasionally will also have pain in the buttocks

Ambulatory/Outpatient - 12/6/2021 Pg. 15

FACILITY: Ortho NorthEast

Provider(s): Cindy M. Fordyce PA

Key Concept(s): condition(800), osteoarthritis(800), pain(800), tibial tendonitis(800)

Narrative(s):
(Assessment/Plan) Left ankle primary osteoarthritis, right ankle primary osteoarthritis, left posterior tibial tendonitis
and right posterior tibial tendonitis has not changed. Plan She was instructed to be weaning from fixed ankle walker to a
shoe with her insert. If she does not get better from the insert then a refer her to Dr. Karr for consultation. She has
already been through the boot casting an insert in the past. We will see how she progresses over the next coming weeks.
Eva should follow-up with Cindy Fordyce PA as needed for orthopedic care, and call the ONE office with any questions
or concerns. Eva is not a surgical candidate at this time. Eva should follow-up with JointONE as needed for orthopedic
care, and call the ONE office with any questions or concerns for Hip pain. Eva should follow-up as needed for orthopedic
care, and call the ONE office with any questions or concerns. Patient evaluated and treated by Cindy Fordyce PA. Scott
D. Karr MD was in the office supervising care.

(History of Present Illness (HPI)) Eva is a 56 year old who comes in today for reevaluation of the eft ankle primary
osteoarthritis, right ankle primary osteoarthritis, left posterior tibial tendonitis and right posterior tibial tendonitis. The
patient is not on narcotic pain meds. The patient states that they are having a stinging pain which they rate between 1
and 2 on a scale from 1 -10. The patient states that pain occurs with activity. The patient states their condition has
significantly improved.
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_X_____ Assist with legal issue (Social Security Claim)

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Social Security Administration OMB No. 0960’0527

Claimant’s Social Security Number J

Claimant's Appointment of a Representative

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Mailing Address
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My- claim is based on anotherI person’s work or earninos *- T I spouse or1 parent).
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X By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release information in relation to my
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Section 5 - Representative's Status, Affiliations, and Certifications (Rep rsenta ti vO n ly)

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Form SSA-1696 (09-2019) UF - 5 of 6

Paqe

Claimant's Social SecurityJ Number

Section 5 - Continued (Representative Only)

Affiliation Information
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* I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
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rights described in Section 6 of this form.

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including any information, attestations and certifications provided to SSA in registration, and that they are all currently true and correct to the
best of myX knowledge
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I CERTIFY TO ALL OF THE ABOVE MeA Pe ca *e*i/e ‘c Fjijia;c

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Section 6 - Claim Type (Clamant or Representative)

I appoint the individual named in Section 4 to act as my representative in connection with my Claims) or asserted rights) under Title 2
(RSDI), Title 16 (SSI), Title 18 (Medicare Coveraqe), and Title 8 (SVB) of the Social Security Act as presently amended, specifically for the
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X I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this box if you
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Ortho NorthEast, 5050 N Clinton St Medical Office, Fort Wayne, IN 46825 March 29, 2022
2604848551 or 800-589-8551 Fax: 2604825060 Page 1

Patient Name: Eva M Woodworth D.O.B: 04/19/1965 (56) ONE#: 10662803

12/16/2021 - Office Visit: NP Rt Hip #8

Provider: Jonathan R Lynch MD
Location of Care: ONE North Medical Office

Provider: Jonathan R. Lynch MD

HPI
Eva is a 56 year old patient whose main reason for today's visit is pain in the right hip with giving way
which has been present for 2 years. The patient denies an injury. The patient is not on narcotic pain
meds. The patient states that they are having a sharp pain which is rated between 3 to 10 on a scale
from 1-10. The pain occurs all the time. She denies the inability to rise out of bed or from a chair without
assistance. She experiences hip stiffness that limits daily activities, hip pain at night and the need for
rest periods when walking due to hip pain. The patient denies having any other symptoms. Treatments
which gave relief include heat. Treatments which sometimes gave relief include
medications:PREDNISONE for as needed. Treatments which did not give relief include joint injections
performed by Elkart. States her pain is in the groin. Does not radiate. Occasionally will also have pain in
the buttocks.
Review of Systems:
Patient denies: Abdominal Pain Bleeding, Chest Pain, Convulsions/Seizure, Decreased Motion,
Depression, Difficulty Swallowing, Easy Bruisability, Emotional Disturbances, Eyes or Vision Problems,
Fecal Incontinence, Fever/Chills, Headaches, Increased Thirst, Increased Hunger, Insomnia,
Musculoskeletal Pain, Nausea/Vomiting, Night Sweats, Poor Balance, Persistent Cough, Rash,
Shortness of Breath, Shortness of Breath White Lying down, Skin Problems, Urinary Retention and
Weakness.
Allergies:
* metal - negative
* ivp dye [hives/dyspnea] (moderate)
cortisone [nausealheadache ] (moderate)
Medications:
tizanidine 2 mg tablet (tizanidine) take 1 tablet by mouth twice a day as needed for muscle spasm
* vitamin d (cholecalciferol) 3 once a day
* tresiba solution
* trazodone hel tablet also known as desyrel
celebrex 50 mg capsule (celecoxib)
furosemide unspecified unspecified (furosemide)
buspirone unspecified unspecified (buspirone)
linzess unspecified unspecified (linaclotide)
glipizide unspecified unspecified (glipizide)
amlodipine unspecified unspecified (amlodipine)
* potassium aminobenzoate unspecified unspecified (potassium aminobenzoate)
divalproex unspecified unspecified (divalproex)
divalproex unspecified unspecified (divalproex)
divalproex unspecified unspecified (divalproex)
lisinopril tablet (lisinopril tabs)
Patient History of:
BLOOD CLOTS/EMBOLISM - NEGATIVE
BLOOD CLOTS - NEGATIVE
MENOPAUSE
DIABETES - TYPE 1 (CURRENTLY ORAL MEDICATION/OFF INSULIN-SINCE WEIGHT LOSS)
Surgical History:
RELEASE OF THE NERVE TO THE ADDUCTOR DIGITI QU I NT I (05/07/2013)
PLANTAR FASCIAL RELEASE(05/07/2013)
2nd ID CONFIRMED

Ortho NorthEast, 5050 N Clinton St Medical Office, Fort Wayne, IN 46825 March 29, 2022
2604848551 or 800-589-8551 Fax: 2604825060 Page 2

Patient Name: Eva M Woodworth D.O.B: 04/19/1965 (56) ONE#: 10662803

TONSILLECTOMY*
HYSTERECTOMY-TOTAL
GALLBLADDER/CHOLECYSTECTOMY
(D&C) DILATION AND CURETTAGE
NO PREVIOUS ORTHOPAEDIC SURGERY
Known Family History of:
heart disease-grandparent
heart disease-father
stroke-mother
cancer-grandparent
cancer-father
Social History:
Social history taken on 12/16/2021 states Eva M Woodworth is a married 56 year old patient. They quit
using tobacco products in 2001.

The patient has had an influenza vaccine between 09/30/2021 and 04/01/2022.

Past medical, social, family histories and ROS reviewed today with the patient and changes
documented in the chart (12/16/2021).
Physical Exam
Height(12/06/2021): 70.5 in. Weight 12/16/2021): 343.8 lbs. BMI: 48.81

Gait: normal Ambulation: patient ambulates without assistive devices

MentallHEENT/SardiolSkin
The patient’s general appearance was well nourished, well hydrated, no acute distress. The patient was
alert and oriented x 3. The patient’s mood was normal. Pulmonary exam shows normal air exchange, no
labored breathing, or shortness of breath. A skin exam showed normal temperature and color in the area
of examination. A lymphatic exam revealed no adenopathy in the area of examination.

Right Hip/Pelvls
Skin is normal.Neurovascular status is intact. Sensation in hip is normal. DP Pulse is 3+. PT PULSE is
3+ Capillary Refill is normal. Reflexes are normal.
ROM
Internal Rotation: <30 degrees
External Rotation: <40 degrees
Abduction: <45 degrees
Adduction: <15 degrees
Flexion: <100 degrees
Extension: <5 degrees

Tenderness
Location: groin
Radiation of Pain: anterior thigh
Pain w/ Palpation: none
Faber Test: negative
Impingement: negative
Straight Leg Raise: negative
Ortho NorthEast, 5050 N Clinton St Medical Office, Fort Wayne. IN 46825 March 29, 2022
2604848551 or 800-589-855* Fax 2604825060 Page 3

Patient Name: Eva M Woodworth D.O.B: 04/19/1965 (56) ONE#: 10662803

Strength
Quad: normal
Abduction: normal
Adduction: norma!
Flexion: normal
Extension normal

Imaging/Diagnostic Studies
X-ray images Right Hip 3 views of [AP;AP pelvis,Frog Lateral] were ordered and reviewed in office today.

X-rays of the right hip/pelvis show mild osteoarthritis, X-rays show sclerosis,
impression
Right hip primary osteoarthritis Grade 2 (minimal)

Plan
Eva is here today for evaluation of right hip pain. Denies injury. States the pain has been going on for
about 2 years. States the pain is in the groin. Does not radiate. Denies backfradicular symptoms.
Examination has pain with range of motion to the right groin, X-rays taken today demonstrate mild OA,
Conservatiwe measures were discussed. At this time I would recommend the patient attempt to lose
some weight to improve her pain. A referral to Dr. Gerhardtstein for weight loss. She can continue to
rest, ice, modify activity, take antiinflammatories as needed. I will see her back as needed Consultation
ordered. ONE test scheduling will contact patient .to assist with scheduling.

Eva should follow-up with me as needed for orthopedic care, and call the ONE office with any questions
or concerns.

Electronically signed by Jonathan R Lynch MD on 12/16/2021 at 4:06 PM

Ortho NorthEast, 5050 N Clinton St Medical Office, Fort Wayne. IN 46825 March 29, 2022
2604848551 or 800-589-855* Fax 2604825060 Page 1

Patient Name: Eva M Woodworth D.0B; 04/19/1965 (56) ONE#: 10662803

12/06/2021 - Office Visit: Rck Left ankle #12

Provider: Cindy M. Fordyce PA
Location of Care: ONE North Medical Office

PA/NP/PoA: Cindy Fordyce PA

Supervising Physician: Scott D. Karr MD
HPI
Eva is a 56 year old who comes in today for reevaluation of the eft ankle primary osteoarthritis, right ankle
primary osteoarthritis, left posterior tibial tendonitis and right posterior tibial tendonitis. The patient is not
on narcotic pain meds. The patient states that they are having a stinging pain which they rate between 1
and 2 on a scale from 1 -10. The patient states that pain occurs with activity. The patient states their
condition has significantly improved.
Review of Systems:
Patient denies: Abdominal Pain, Bleeding, Chest Pain, Convulsions/Seizure, Decreased Motion,
Depression, Difficulty Swallowing, Easy Bruisability, Emotional Disturbances, Eyes or Vision Problems,
Fecal Incontinence, Fever/Chills, Headaches, Increased Thirst, Increased Hunger, Insomnia,
Musculoskeletal Pain, NauseaA/omiting, Night Sweats, Poor Balance, Persistent Cough, Rash,
Shortness of Breath, Shortness of Breath While Lying down, Skin Problems, Urinary Retention and
Weakness.
Allergies:
* metal - negative
* ip dye- [hives/dyspnea] (moderate)
cortisone [nausealheadache ] (moderate)
Medications:
tizanidine 2 mg tablet (tizanidine) take 1 tablet by mouth twice a day as needed for muscle spasm
* vitamin d (cholecalciferol) 3 once a day
* tresiba solution
* trazodone hci tablet also known as desyrel
celebrex 50 mg capsule (clecoxib)
furosemide unspecified unspecified (furosemide)
buspirone unspecified unspecified (buspirone)
linzess unspecified unspecified (linaclotide)
glipizide unspecified unspecified (glipizide)
amlodipine unspecified unspecified (amlodipine)
* potassium aminobenzoate unspecified unspecified (potassium aminobenzoate)
tramadol 50 mg tablet (tramadol) '
divalproex unspecified unspecified (divalproex)
divalproex unspecified unspecified (divalproex)
divalproex unspecified unspecified (divalproex)
lisintopril tablet (lisinopril tabs)
Patient History of:
BLOOD CLOTS/EMBOLISM - NEGATIVE
BLOOD CLOTS - NEGATIVE
MENOPAUSE
DIABETES - TYPE 1 (CURRENTLY ORAL MEDICATION/OFF INSULIN-SINGE WEIGHT LOSS)
Surgical History:
RELEASE OF THE NERVE TO THE ADDUCTOR DIGITI QU INTI (05/07/2013)
PLANTAR FASCIAL RELEASE(05/07/2013)
TONSILLECTOMY*
HYSTERECTOMY-TOTAL
GALLBLADDER/CHOLECYSTECTOMY
Ortho NorthEast, 5050 N Clinton St Medical Office, Fort Wayne, IN 46825 March 29, 2022
2604848551 or 800-589-8551 Fax: 2604825060 Page 2

Patient Name: Eva M Woodworth D.O.B: 04/19/1965 (56) ONE#: 10662803

(08C) DILATION AND CURETTAGE

NO PREVIOUS ORTHOPAEDIC SURGERY
Known Family History of:
heart disease-grandparent
heart disease-father
stroke-mother
cancer-grandparent
cancer-father
Social History:
Social history taken on 10/12/2021 states Eva M Woodworth is a married 56 year old female. She quit
using tobacco products in 2001.

Past medical, social, family histories and ROS reviewed today with the patient and changes
documented in the chart (12/06/2021),
Physical Exam
Height(1 2/06/2021): 70.5 in Weight(1 2/06/2021): 330 lbs. BMI: 46.85

Recheck
There is no edema. There is no warmth. There is no effusion. There is no drainage. There is no
erythema. There is no necrosis. There is no ecchymosis. No clinical signs of infection. No clinical signs
of DVT. There is minimal swelling. There is no tenderness. Calf soft, non-tender. Pulse is normal.
Capillary refill is normal.

Imaging/Diagnostic Studies
No x-rays were obtained today.
Impression
Left ankle primary osteoarthritis, right ankle primary osteoarthritis, left posterior tibial tendonitis and right
posterior tibial tendonitis has not changed.

Plan
She was instructed to be weaning from fixed ankle walker to a shoe with her insert. If she does not get
better from the insert then a refer her to Dr. Karr for consultation. She has already been through the boot
casting an insert in the past. We will see how she progresses over the next coming weeks.

Eva should follow-up with Cindy Fordyce PA as needed for orthopedic care, and call the ONE office with
any questions or concerns. Eva is not a surgical candidate at this time. Eva should follow-up with
JointONE as needed for orthopedic care, and call the ONE office with any questions or concerns for Hip
pain. Eva should follow-up as needed for orthopedic care, and call the ONE office with any questions or
concerns.

Patient evaluated and treated by Cindy Fordyce PA. Scott D. Karr MD was in the office supervising care.

Electronically signed by Cindy M. Fordyce PA on 12/06/2021 at 1:22 PM

Electronically signed by Scott D. Karr MD on 12/06/2021 at 1:33 PM