The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. 124 TH THE LIGHT OF HOPE SESSION. June 18 20, 2018 in York, PA.

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1 The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. 124 TH THE LIGHT OF HOPE SESSION General Chairman 458 Gleneagle Ct. Monroeville, PA (H) January 2018 June 18 20, 2018 in York, PA Co-Chairman Madelyn M. Kemp 8416 Seemsville Road Northampton, PA (H) Secretary Michele A. Marshall Treasurer Tina M. Haley Choir Director Cherie L. Thomas Daily Luncheons Cynthia L. Kaufman Decorations Deborah L. Griffiths Divine Service/Necrology Evelyn B. Kohl Grand Banquet Teri H. Seiter Honors and Protocol Susan Gotta Hospitality Connie F. Wood Housing Linda L. Shafer Out-Of-State Entertainment Nancy E. Younker Pages Carla R. Holderbaum Paraphernalia Richard D. Wary Saturday Night Entertainment Kathleen L. Hahn Souvenirs Patricia A. Longwell Dear Sisters and Brothers, The 124 th Session of the Grand Chapter of Pennsylvania, Order of the Eastern Star, Inc., The Light of Hope Session will convene on Monday, June 18 th, 2018 at the York Expo and Convention Center, Utz Arena, in York, Pennsylvania. The Session Committee is planning an unforgettable week for our members and Out-of-State visitors! The headquarters for the The Light of Hope Session will be at the Homewood Suites located at 200 Masonic Drive, York, PA Enclosed you will find all the information and details pertaining to each event. All proper forms are included for your reservation which must be accompanied by payment in full. ALL checks are payable to Grand Chapter of PA OES, Inc. (unless otherwise specified) and all must be in US funds. You may also find the necessary forms on the following website: PLEASE INDICATE SPECIAL DIETARY RESTRICTIONS ON YOUR REGISTRATION FORM OTHERWISE NONE WILL BE HONORED THE DAY OF THE EVENT! The 124 th Session Committee truly hopes you will have a wonderful experience at The Light of Hope Session. Please feel free to call if you have any questions or if we can be of further assistance to you. May God give you safe travels! Madelyn M. Kemp Madelyn M. Kemp 124 th Session, Chairman 124 th Session, Co-Chairman Transportation and Vendors Donald L. Gladfelter

2 The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. 124 TH THE LIGHT OF HOPE SESSION June 18 20, 2018 in York, PA January 2018 Greetings, The 124 th Session of the Grand Chapter of Pennsylvania will be held in York, Pennsylvania on June 18-20, This will be an historic and exciting Session because every member of a Chapter in Pennsylvania is now eligible to vote. Registration is accomplished through your Deputy Grand Matron. The events form you complete also serves as your registration information. Follow the payment instructions on the form. All members must have a valid dues card in order to receive registration materials at the Session. The cost for pre-registration is $ The deadline for pre-registration is May 15, Registrations that are received after that date will be $20. Registration will also be available onsite in York at a cost of $20. Please note: New Golden Stars attending only the special Golden Stars ceremony will not need to register. Eligible Golden Stars will receive information from the Golden Stars Committee. Also, members attending only the Installation Ceremony on Wednesday, June 20, 2018 will not need to register. However, a valid dues card must be presented for admittance. Looking forward to registering you, HelenBeth G. Vilcek HelenBeth G. Vilcek, PGM Registration Chairman

3 124th THE LIGHT OF HOPE Grand Chapter Session - June 18-20, 2018 Registration Form Pennsylvania Member Please submit this form to your DGM as soon as possible, but no later than May 15, Enclose a check made out to Grand Chapter of PA OES, Inc. Memo 124 th Session. All checks must be in U.S. Currency. (Black Ink Only) Remember that you are responsible for making your own reservation for housing. Contact your DGM with any questions. DGM Name: Region No: PLEASE PRINT YOUR NAME AS IT APPEARS ON YOUR DUES CARD. NAME: (First) (Middle Initial) (Last) (Jr., Sr., etc.) TITLE IN JUNE 2018: Phonetic Spelling of Your Name for Introduction Purposes: ADDRESS: PHONE: ( ) - CITY: STATE: ZIP: ADDRESS: CELL: ( ) - PRIMARY CHAPTER NAME: NO: REGION NO: SECONDARY CHAPTER NAME: NO: REGION NO: Circle your Title in June 2018: WM WP AM AP You will be registered through your primary chapter unless you are a WM, WP, AM, or AP of your secondary chapter. FOR SAFETY CONCERNS, PLEASE LIST HOTEL / PLACE STAYING: Saturday Night Entertainment Celtic Kind of Night $ $ Grand Banquet A Military Ball $ $ Monday Giving of the Green Charity Luncheon $ $ Sight & Sound Trip Jesus Anchor of Hope Excursion $ $ Tuesday Lucky Charm Election Day Box Lunch Turkey & Cheese or Ham & Cheese $ $ Registration Fee (add $5 fee after deadline) $15.00 $ TOTAL COST (check to be enclosed) Payable to: Grand Chapter of PA, OES, Inc. $ Divine Worship check if attending Free PLEASE NOTE SPECIAL DIETARY RESTRICTIONS (none will be considered if not listed) Registration Deadline: Postmarked by May 15, 2018 (No refunds after this date) Meal tickets will be available at Emily s Cove" -- Information Booth and Gift Shop

4 The Light of Hope Session All events will be held in the York Expo & Convention Center, UTZ Arena 334 Carlisle Avenue, York, PA Phone: (unless otherwise stated) Saturday, June 16, :30 AM Past Grand Matrons & Past Grand Patrons Dinner Outdoor Country Club, 1157 Detwiler Road, York, PA Ph: Reservations: $22.00 by May 15, 2018 Checks payable to: Mary A. Haas, PGM 76 Green Street, Houston, PA Ph: / mahaas76@comcast.net 6:30 PM Celtic Kind of Night Saturday Night Entertainment Doors open 5:30 PM Reservations: $34.00 by May 15, 2018 Checks payable to: Grand Chapter of PA, OES, Inc. Contact: Kathleen L. Hahn, AGCCM Ph: / hahnkathleen@yahoo.com Sunday, June 17, :00 AM Divine Worship Service, Communion, and Necrology Reservations by May 15, 2018 Contact: Evelyn B. Kohl, AGCCM Ph: / evkohl@comcast.net 10:30 AM Presentation of Educational Scholarship and ESTARL Awards 11:30 AM Recognition of Golden Stars Contact: Margaret M. Kauffman, AGCCM Ph: / pkauff51@comcast.net 12:30 PM Keystone Eagle Corporation Meeting 1:30 PM Deputy Grand Matrons Luncheon (by invitation only) Reservations: $20.00 by May 15, 2018 Wyndham Garden, 2000 Loucks Road, York, PA Contact: Madelyn M. Kemp, AGCCM Ph: / maggie.usa13@gmail.com Only DGMs will pick up AGCCM packets at Happy Trails Club Board Table immediately following Golden Stars Recognition. 2:30 PM Men s Seminar the Verandah Room 2:30 PM Secretary s Seminar the Verandah Room 6:30 PM A Military Ball Grand Banquet Honoring the Worthy Grand Matron and Worthy Grand Patron Reservations: $35.00 by May 15, 2018 Checks payable to: Grand Chapter of PA, OES, Inc. Doors open 5:30 PM Contact: Teri H. Seiter, AGCCM Ph: / seitet@verizon.net Monday, June 18, :00 AM Harvesting Our Friendships Keystoners Breakfast Keystoner Members and Present Counterparts, Past and Present Grand Representatives of Other Grand Jurisdictions are Welcome! The Verandah Room Reservations: $20.00 by May 15, 2018 Checks payable to: The Keystoners Contact: Mary Ann Rhode, Grand Secretary Emeritus 5224 Route 419, Womelsdorf, PA Ph: / marhode@comcast.net 9:00 AM Grand Chapter Called To Order Formal Opening Memorial Service Partial Report of Credentials Committee Reports Business of Session 12:00 PM Giving of the Green Charity Luncheon Reservations: $24.00 by May 15, 2018 Checks payable to: Grand Chapter of PA, OES, Inc. Contact: Cynthia L. Kaufman, AGCCM Ph: / ckaufman450@gmail.com 1:30 PM Grand Chapter Called To Order Report of Fraternal Correspondent Business Session 5:30 PM Organ Recital 6:00 PM Informal Opening Entrance of Grand Officers Entrance of Deputy Grand Matrons Grand Pages Drill Presentation of Flags Presentation of Bibles and Emblems Introduction of Charitable Donation Recipients Grand Chapter Called to Order Entrance of Grand Officers Address of Welcome by:, General Chairman, 124 th Session Madelyn M. Kemp, Co Chairman, 124 th Session Partial Report of Credentials Committee Presentation of Distinguished Guests NOTE: All checks must be in US Currency and payable to Grand Chapter of PA, OES, Inc. Memo line 124 th Session Pennsylvania members will make reservations through their Deputy Grand Matron unless otherwise stated. Tuesday, June 19, :00 AM Out Of State Visitors Trip Jesus Anchor of Hope Excursion Reservations: $89.00 by May 15, 2018 Sight & Sound Theater Production of Jesus Contact: Nancy E. Younker, AGCCM Ph: / nancyy@frontiernet.net 9:00 AM Election Day Grand Chapter Called to Order Reading of Minutes Partial Report of Credentials Committee Election of Grand Officers Continuation of Reports Lucky Charm Election Day Box Lunch $10.00 Checks payable to: Grand Chapter of PA, OES, Inc. Business of Session Reception Honoring the Associate Grand Conductress Elect (in front of the doors of the Grand Banquet Room) immediately following the close of the Business Session. Wednesday, June 20, :00 AM Grand Page Breakfast (by invitation only) Honoring the Worthy Grand Matron and Worthy Grand Patron Wyndham Garden, 2000 Loucks Road, York, PA :00 AM Grand Chapter Called To Order Reading of Minutes Continuation of Reports Business of Session Final Report of Credentials Committee Report of Registration Committee Bible Signing Ceremony Ritualistic Closing 11:30 AM P.A.G.O. (Past Appointed Grand Officers) Luncheon, (by invitation only) Out of State PAGOS are welcome. The Verandah Room Reservations: $22.00 by May 15, 2018 Contact: E. Darlene Andrews, PM 1136 McKinley Drive, Clairton, PA Ph: / edarleneandrews@comcast.net 2:00 PM Installation Entrance of Grand Officers Entrance of Deputy Grand Matrons & Deputy Grand Matrons Grand Pages Drill Grand Chapter Called to Order Installation of Grand Officers

5 The Light of Hope Session General Chairman Co Chairman Madelyn M. Kemp 458 Gleneagle Court 8416 Seemsville Road Monroeville, PA Northampton, PA GENERAL INFORMATION Credentials and Registration Committees will provide services at the York Expo and Convention Center at the UTZ Arena as noted: Saturday, June 16, :00 PM to 5:00 PM Sunday, June 17, 2018 Following Golden Star Ceremony (for a period of three hours) Monday, June 18, :30 AM to 10:30 AM (If there is a PM meeting, 1:00 PM to 2:00 PM) 5:00 PM to 7:00 PM Out of State Only 1:00 PM to 7:00 PM Tuesday, June 19, :00 AM to 9:00 AM and one hour immediately following Close of Election Wednesday, June 20, :00 AM to 10:00 AM A registration fee of $15.00 ($20.00 after May 15, 2018) shall be charged to EVERYONE who attends any or all of the Grand Chapter Sessions, including out of state visitors. A current signed dues card must be presented at the registration desk, where attendees will receive the registration card which must be presented for admittance to all meetings. FIFTY YEAR MEMBERS attending only the special program in their honor do not need to register. PRE REGISTRATION IS AVAILABLE TO EVERYONE The deadline for pre registration is May 15, 2018 Visitors From Other Jurisdictions with questions should contact the Honors and Protocol Chairman: Susan L. Gotta, AGCCM 1804 Yardley Commons, Yardley, PA 19067; Phone: ; sgotta@msn.com. Registration fee is $ ($20.00 after May 15, 2018) Checks only in U.S. currency payable to: Grand Chapter of PA, OES, Inc. Memo line: 124 th Session Please check in at the Out of State Registration Desk upon arrival. HOSPITALITY ROOM Located in West Promenade (Open To: Out Of State Guests, Grand Officers, Past Grands, Session Committee) Sunday: Following the Recognition of Golden Stars to 3:30 PM Monday: 8:00 AM to 11:00 AM and 4:00 PM to 7:00 PM Tuesday: 8:00 AM to 8:45 AM, and one hour following the Close of the Business Session for the final Gift Bag pick up. Wednesday: 8:30 AM to 1:30 PM ATTENTION OUT OF STATE VISITORS Attendees will make their own hotel reservations. If you need help with your hotel reservations, please contact by April 15, 2018: Linda L. Shafer, AGCCM, P.O. Box 20544, Lehigh Valley, PA Phone: / dogpowered@aol.com The headquarters for The Light of Hope Session is the Homewood Suites by Hilton, 200 Masonic Drive, York, PA Phone: DAILY CASH FOOD SERVICE will be available at the UTZ Arena: Saturday 8:00 AM to 3:00 PM; Sunday 7:00 AM to 3:00 PM; Monday 7:00 AM to 6:00 PM; Tuesday 7:00 AM to 4:00 PM; and Wednesday 7:00 AM to 2:00 PM. VENDORS will be located in the East Wing of the UTZ Arena, and will be open as follows: Saturday: 12:00 PM to 5:30 PM Sunday: 12:00 PM to 5:30 PM Monday & Tuesday: 8:00 AM to 5:00 PM Wednesday: 8:00 AM to 12:00 PM REHEARSALS All rehearsals will be held in the Grand Chapter Room, UTZ Arena, unless otherwise stated. GRAND OFFICERS with Personal Pages Friday, June 16, 2:00 PM to 6:00 PM GRAND OFFICERS with Installing Officers, Personal Pages Saturday, June 16, 8:00 AM to 10:30 AM PAGES Personal Pages with the Grand Officers Friday, June 15, 2:00 PM to 6:00 PM Saturday, June 16, 8:00 AM to 10:30 AM All Pages Drills and Divine Service Saturday, June 16, 10:30 AM to 12:30 PM Sunday, June 17, 12:45 PM to 2:00 PM with Chairman of Elections DEPUTY GRAND MATRONS and Saturday, June 16, 2:45 PM to 3:15 PM, with Grand Conductress, Associate Grand Conductress, and candidates for Associate Grand Conductress ASSISTANT GRAND WARDERS and GRAND GUARDS Saturday, June 16, 12:30 PM to 1:30 PM With Joan A. Miller, Grand Warder and Robert E. Holderbaum, Grand Sentinel CHAIR PRACTICE from 12:30 PM to 1:00 PM FLAG, BIBLE, and EMBLEM BEARERS Saturday, June 16, 1:30 PM to 2:00 PM FRATERNAL CORRESPONDENT Saturday, June 16, 2:00 PM to 2:45 PM NECROLOGY Saturday, June 16, 3:15 PM to 3:45 PM CHOIR Saturday, June 16, 12:30 AM to 3:30 PM Location: Calvary United Methodist Church, 11 North Richland Avenue, York, PA Sunday June 17: 2:00 PM to 4:30 PM Location: Grand Chapter Room Sunday Wednesday: 7:30 AM in the Grand Chapter Room (Plus as called by Cherie Thomas, 124 th Session Choir Director) The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. extends fraternal greetings and a cordial invitation to attend the One Hundred Twenty-Fourth The Light of Hope Session June 18 20, 2018 York Expo and Convention Center UTZ Arena York, Pennsylvania Emily D. McCarthy Donald C. Graver Worthy Grand Matron Worthy Grand Patron Virginia L.Plyler, PGM Grand Secretary SECRETARIES: Please read only the above invitation then give to your Worthy Matron attending the Session. It is not necessary to read the detailed program in your chapter.

6 Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. 124 th The Light of Hope Session June 18-20, 2018 Dear Sisters and Brothers, As you prepare for the 124 th Session of Grand Chapter, The Light of Hope Session, we would like to inform you of the proper dress code for the events. Celtic Fun Night Saturday Night Entertainment Daytime Session Meetings Sunday Divine Service Luncheon Casual Slacks, Capris, or Jeans (no shorts) (please wear something green or plaid) Business Attire: Ladies Suit, Dress, or Skirt & Blouse Men Suit with Dress Shirt & Tie Evening Session Meetings Sunday Grand Banquet Formal Attire: Ladies Gown or Cocktail Dress Men Tuxedo or Suit with Dress Shirt & Tie Please no slacks, shorts, skorts or jeans, except where noted. Deputy Grand Matrons please make copies and give to all members in your Region who are attending The Light of Hope Session. The 124 th Session Committee looks forward to seeing you at The Light of Hope Session. Thank you in advance for your cooperation in adhering to the above dress code. Fraternally, 124 th Session General Chairman

7 General Chairman 458 Gleneagle Ct. Monroeville, PA (H) Co-Chairman Madelyn M. Kemp 8416 Seemsville Road Northampton, PA (H) Secretary Michele A. Marshall Treasurer Tina M. Haley Choir Director Cherie L. Thomas Daily Luncheons Cynthia L. Kaufman Decorations Deborah L. Griffiths Divine Service/Necrology Evelyn B. Kohl Grand Banquet Teri H. Seiter Honors and Protocol Susan L. Gotta Hospitality Connie F. Wood Housing Linda L. Shafer Out-Of-State Entertainment Nancy E. Younker Pages Carla R. Holderbaum Paraphernalia Richard D. Wary Saturday Night Entertainment Kathleen L. Hahn The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. 124 TH THE LIGHT OF HOPE SESSION January 2018 June 18 20, 2018 in York, PA Dear Sisters and Brothers, It is with great pleasure that I extend an invitation to the members of the Grand Chapter of Pennsylvania, Order of the Eastern Star, their families, friends, and guests to worship with our Worthy Grand Matron, Worthy Grand Patron and Grand Officers at the Divine Service and Necrology Service. The services will be held on Sunday, June 17, During the service I hope you will join with your sisters and brothers at the table of Holy Communion. The service will begin at 9 AM in the York Expo and Convention Center, UTZ Arena. During the Worship Service, the annual Necrology Service will be held. I hope and pray that you will find these services meaningful. In order to prepare for the service, it would be greatly appreciated if you would indicate on your registration form the approximate number of visitors and guests planning to attend. There will be a brief procession prior to the beginning of the service. Please plan to be in your seats by 8:45 AM so that the procession may begin on time. I look forward to meeting you at the 124 th The Light of Hope Session and truly appreciate your cooperation and assistance in preparing for the service that will begin our Grand Chapter s work by asking God s help in doing so. With God s Blessings, Evelyn B. Kohl, AGGCM Divine Service and Necrology Souvenirs Patricia A. Longwell plongwell@rocketmail.com Transportation and Vendors Donald L. Gladfelter morewood1@verizon.net

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9 The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. cordially invites you to attend the Grand Banquet, our version of: A Military Ball Honoring Sister Emily D. McCarthy, WGM And Brother Donald C. Graver, WGP Sunday, June 17, 2018 Doors Open 5:30, Dinner Begins 6:30 York Expo and Convention Center Utz Arena, York, Pennsylvania Tickets $35.00 Checks payable to the Grand Chapter of PA, OES, Inc. All Reservations must be made using the Session Registration Form Reservation close date: May 15, 2018 Dietary restrictions for meals must be pre-ordered Military Dress is Welcome

10 Charity Luncheon Presentations will be made to Multiple Sclerosis and Cancer Organizations Monday June 18, :00 PM York Expo and Convention Center Utz Arena, York, PA Subscription: $24.00 Checks payable to Grand Chapter of PA, OES Inc. Reservations must be made using the Registration Form with a courtesy reply by May 15, Please indicate dietary restrictions on registration form - special requests cannot be accepted the day of the event!

11 General Chairman 458 Gleneagle Ct. Monroeville, PA (H) Co-Chairman Madelyn M. Kemp 8416 Seemsville Road Northampton, PA (H) Secretary Michele A. Marshall Treasurer Tina M. Haley Choir Director Cherie L. Thomas Daily Luncheons Cynthia L. Kaufman Decorations Deborah L. Griffiths Divine Service/Necrology Evelyn B. Kohl Grand Banquet Teri H. Seiter Honors and Protocol Susan L. Gotta Hospitality Connie F. Wood Housing Linda L. Shafer Out-Of-State Entertainment Nancy E. Younker Pages Carla R. Holderbaum Paraphernalia Richard D. Wary Saturday Night Entertainment Kathleen L. Hahn The Grand Chapter of Pennsylvania Order of the Eastern Star, Inc. 124 TH THE LIGHT OF HOPE SESSION January 2018 June 18 20, 2018 in York, PA Lucky Charm Election Day Luncheon Dear Sisters and Brothers, The 124 th Session of the Grand Chapter of Pennsylvania, Order of the Eastern Star, Inc., The Light of Hope Session will reconvene on Tuesday, June 19, 2018 for the election of Grand Officers and Committee Members. Please join us for lunch as we make decisions that will affect this Grand Chapter. The Lucky Charm boxed lunch will be served in the Grand Chapter room at approximately 11:30 AM while the business of Grand Chapter continues. Tickets for the lunch are $10.00 with a choice of Ham & Cheese Sandwich or Turkey & Cheese Sandwich. Please specify your meal choice on the Registration form and indicate special dietary restrictions. Special meal requests cannot be accepted the day of the lunch. The Grand Pages will collect your lunch ticket when your meal is delivered to you. We are happy to invite all pages and nurses to be our guests for the election day lunch please write-in Page or Nurse next to your meal choice on the registration form. Reservation will be accepted through May 15, There will be no refunds after this date. All reservations and refund requests must be made by you to your Deputy Grand Matron. Wishing you luck today and every day! Fraternally, Cynthia L. Kaufman 124 th Session Committee Daily Luncheons Souvenirs Patricia A. Longwell plongwell@rocketmail.com Transportation and Vendors Donald L. Gladfelter morewood1@verizon.net

12 Grand Chapter of Pennsylvania Order of the Eastern Star presents for the 124th Session the first excursion of the USS HOPE: Tuesday, June 19, 2018 Jesus' story may be familiar, but His actions still surprise us. He befriends outcasts and heals the hurting. He challenges social norms and confronts hypocrisy. He sets sail with fishermen and reasons with religious scholars. The lives He touches are never the same. From the streets of Jerusalem to the raging Sea of Galilee, no place--and no person--is beyond the reach of His love Come join us on our first excursion from the USS HOPE. Our tender wlll take us from the Utz Arena in York, PA to Sight and Sound in Lancaster County to see the new production of "Jesus". We will meet our tender at 9:15 a.m. at the main entrance of the Utz Arena. We wlll arrive in plenty of time to make a bathroom stop before the show at 11:00 a.m. Following the show, we will once again board our tender and head to Shady Maple Restaurant where we will have lunch from the delicious smorgasbord or order from the menu. The cost of the smorgasbord is: $14.39 and seniors $ Lunch is on your own. Following lunch you may want to browse the 40,000 square feet of gift shops. We will leave Shady Maple at 3:00 p.m. in order to arrive back at the USS HOPE by 5:00 p.m. so that you may retire to your stateroom for a llttfe rest before joining others for the evening. Cost of this excursion is $89. This includes your transportation and ticket for the theatre. This is open to Out-of-State visitors, PA OES members and their guests. Name Contact information: I will have a wheelchair I will have a scooter Please return this portion to: Nancy Younker, 2182 Big Cove Tannery Rd. Big Cove Tannery, PA or me at: nancyy@frontiernet.net by June 1st. I need this in order to plan for transportation. Thank you.

13 ' Name: Prima!Y Address:.-. City: Home Phone:. Date of Birth: Blood L RH T~~e: MEDICAL INFORMATION (not required) The Grand Chapter Nurses woutd appreciate it if you would fill out this Information and carry It with you in case of an emergency. NOTiir THIS WIU NOT BE ~OUECTED- PERSONAL USi ONLY In Case of EmergenQl Please Notifv: , Relationshle: "'. State ~ Address: Cell Phone: Sex: SQedal Conditions: Doctor Info: Home Phone: Dr. Phone Number: I.. Cell Phone: Primal): Health Insurance: Polig #: Roommate at Grand Chapter: 0 Arthritis o Asthma 0 Bronchitis o cancer o Diabetes o Dizziness o Emphysema o Epilepsy o Eye Problem o Fainting o Frequent/Severe Headaches D Glaucoma o Hearing Impaired o Heart Condition o Hemodialysis o High Blood Cholesterol Medical History - Mark Appropriate Comments: o High Blood Pressure o Hypoglycemia o Jaundice o Kidney Disease o Low Blood Pressure D Pain in Chest D Palpitations o Periods of Unconsdousness D Rheumatism D Seizures o Shortness of Breath o Stomach, Liver or Intestinal 0 Tumor o Thyroid Problems o Urinary Tract Infection - Comments: Please continue on ~e side. Thonk you/

14 Allergies/Drug Sensitivities Allergy/Sensitivity Type -Include medications, foods, environmental or other.. :.... ~ Mediqmons (dose/frequency) Note: Include all prescription medications (such as nitroglycerin), over-the-counter medications (taken on a regular basis), vitamin supplements and herba'l remedies. ~ '... MedicarDevices - (Example: pacemaker, insulin pumps or.other devices) Device Type Doctor Device Type l:)octor - Hospital Date Hospital Date - Reason Reason Additional Information Additional Information I..