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pdfOMB #0935-0118
15-201
2015 Monthly Planner
41962.0914.6050020301
Eyeglasses or contact lenses
Diabetic equipment and supplies, including insulin
Ambulance services
Crutches, wheelchairs, and other
health-related equipment
n
n
n
n
The date
The name of the provider
The reason for the visit or medical expense
Charges and payments
For each event, note:
n
n
n
n
Also record other medical expenses:
19
26
24
25
31
19
26
24
25
31
27
20
28
21
14
29
22
15
30
23
16
9
28
21
14
7
18
13
8
29
22
15
8
30
23
16
9
2
Tu
17
12
7
1
M
11
6
2
10
5
Sa
F
1
4
23
3
Th
29
22
16
Su
Tu
W
28
21
15
M
30
23
14
Su
29
22
16
9
August 2016
28
21
15
8
July 2016
27
20
14
9
7
18
13
8
31
24
17
10
3
W
24
17
10
3
W
17
12
7
2
Tu
11
6
1
M
10
5
2
4
Sa
F
1
3
Th
Su
W
M
Su
Tu
February 2016
January 2016
2016
25
18
11
4
Th
25
18
11
4
Th
F
26
19
12
5
F
26
19
12
5
27
20
13
6
Sa
27
20
13
6
Sa
28
21
14
7
M
29
22
15
8
1
Tu
30
23
16
9
2
W
25
18
11
4
Su
26
19
12
5
M
27
20
13
6
Tu
28
21
14
7
W
September 2016
27
20
13
6
Su
March 2016
29
22
15
8
1
Th
31
24
17
10
3
Th
F
30
23
16
9
2
F
25
18
11
4
24
17
10
3
Sa
26
19
12
5
Sa
25
18
11
4
M
26
19
12
5
Tu
27
20
13
6
W
17
10
3
M
18
11
4
Tu
23 24
25
30 31
16
9
2
Su
26
19
12
5
W
October 2016
24
17
10
3
Su
April 2016
27
20
13
6
Th
28
21
14
7
Th
F
28
21
14
7
F
29
22
15
8
1
29
22
15
8
1
Sa
30
23
16
9
2
Sa
30
23
16
9
2
M
31
24
17
10
3
Tu
25
18
11
4
W
27
20
13
6
Su
28
21
14
7
M
29
22
15
8
1
Tu
30
23
16
9
2
W
November 2016
29
22
15
8
1
Su
May 2016
24
17
10
3
Th
26
19
12
5
Th
F
25
18
11
4
F
27
20
13
6
26
19
12
5
Sa
28
21
14
7
Sa
27
20
13
6
M
28
21
14
7
Tu
29
22
15
8
1
W
25
18
11
4
Su
26
19
12
5
M
27
20
13
6
Tu
28
21
14
7
W
December 2016
26
19
12
5
Su
June 2016
29
22
15
8
1
Th
30
23
16
9
2
Th
30
23
16
9
2
F
24
17
10
3
F
31
24
17
10
3
Sa
25
18
11
4
Sa
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Notes
n
V
isits to a doctor, dentist, or other health care
provider such as a physical therapist,
chiropractor, or optometrist
n Visits to a clinic or HMO
n Hospital stays
n Visits to an emergency room
n Visits to an outpatient department of a hospital
n Visits for blood tests, X-rays, or other tests
n T
elephone calls to obtain test results or
medical advice
n Admissions to a nursing home
n
Care received at home from a home health care
provider, doctor, nurse, or other health care person
n
Prescriptions for medicines that were filled
or refilled
Use it to make notes about all types of
health care events:
This monthly planner is provided as a convenient way to keep track of health care events for
your family. These events will be asked about during the MEPS interview.
2015 Monthly Planner
27
26
30
26
25
28
29
30
23
31
24
25
18
26
12
5
19
17
11
4
18
16
10
3
23 24
25
30 31
9
2
27
22
17
11
Tu
26
21
16
10
M
20
15
9
4
19
14
8
3
13
7
2
1
W
25
12
24
6
23
18
5
Th
W
Sa
22
17
Su
Tu
F
31
24
16
4
11
M
30
23
15
10
Su
29
22
17
9
3
August 2015
28
21
16
8
2
July 2015
27
20
15
10
1
W
19
14
9
3
Tu
18
13
8
2
1
M
12
7
F
Th
11
6
W
5
Tu
4
27
Su
26
24
25
31
20
13
February 2015
19
18
17
12
6
M
Sa
26
11
5
Su
31
25
10
4
W
26
19
12
5
January 2015
2015
29
24
19
3
28
23
18
12
Tu
27
22
17
11
M
21
16
10
5
20
15
9
4
14
8
3
13
25
18
7
Sa
24
17
6
2
1
F
23
16
11
Su
W
Tu
Th
25
10
M
31
24
9
Su
30
23
18
4
August 2014
29
22
17
3
July 2014
28
21
16
11
2
20
15
10
W
19
14
9
Tu
13
8
M
12
7
4
6
3
5
2
1
Su
Th
W
M
Su
Tu
February 2014
January 2014
27
20
13
6
Th
26
19
12
5
Th
28
21
14
7
Th
27
20
13
6
28
21
14
7
F
27
20
13
6
F
29
22
15
8
1
F
28
21
14
7
29
22
15
8
1
Sa
28
21
14
7
Sa
30
23
16
9
2
Sa
22
15
8
1
29
22
15
8
1
M
30
23
16
9
2
Tu
30
23
16
9
2
M
31
24
17
10
3
Tu
25
18
11
4
W
24
17
10
3
W
27
20
13
6
Su
28
21
14
7
M
29
22
15
8
1
Tu
30
23
16
9
2
W
September 2015
29
22
15
8
1
Su
March 2015
28
21
14
7
Su
September 2014
26
12
5
23 24
25
30 31
11
4
Tu
19
17
10
3
M
18
16
9
2
Su
24
17
10
3
Th
26
19
12
5
Th
25
18
11
4
Th
27
20
13
6
25
18
11
4
F
27
20
13
6
F
26
19
12
5
F
28
21
14
7
26
19
12
5
Sa
28
21
14
7
Sa
27
20
13
6
Sa
29
22
15
8
1
Sa
28
21
14
7
M
29
22
15
8
1
Tu
30
23
16
9
2
27
20
13
6
M
28
21
14
7
Tu
27
20
13
6
M
28
21
14
7
Tu
29
22
15
8
1
W
29
22
15
8
1
W
25
18
11
4
Su
26
19
12
5
M
27
20
13
6
Tu
28
21
14
7
W
October 2015
26
19
12
5
Su
April 2015
26
19
12
5
Su
October 2014
27
20
13
6
Su
W
29
22
15
8
1
Th
30
23
16
9
2
Th
30
23
16
9
2
Th
24
17
10
3
Th
30
23
16
9
2
F
24
17
10
3
F
31
24
17
10
3
F
25
18
11
4
F
31
24
17
10
3
Sa
25
18
11
4
Sa
25
18
11
4
Sa
26
19
12
5
Sa
26
19
12
5
M
27
20
13
6
Tu
28
21
14
7
17
10
3
M
25
18
11
4
Tu
26
27
20
13
6
W
26
19
12
5
W
29
22
15
8
1
Su
30
23
16
9
2
M
24
17
10
3
Tu
25
18
11
4
W
November 2015
19
12
5
Tu
18
17
11
4
M
24
25
31
10
3
Su
May 2015
23
24
30
16
9
2
Su
November 2014
25
18
11
4
Su
W
26
19
12
5
Th
28
21
14
7
Th
27
20
13
6
Th
29
22
15
8
1
Th
27
20
13
6
F
29
22
15
8
1
F
28
21
14
7
F
30
23
16
9
2
F
28
21
14
7
Sa
30
23
16
9
2
Sa
29
22
15
8
1
Sa
31
24
17
10
3
Sa
30
23
16
9
2
M
24
17
10
3
Tu
25
18
11
4
29
22
15
8
1
M
30
23
16
9
2
Tu
29
22
15
8
1
M
30
23
16
9
2
Tu
24
17
10
3
W
31
24
17
10
3
W
27
20
13
6
Su
28
21
14
7
M
29
22
15
8
1
Tu
30
23
16
9
2
W
December 2015
28
21
14
7
Su
June 2015
28
21
14
7
Su
December 2014
29
22
15
8
1
Su
W
31
24
17
10
3
Th
25
18
11
4
Th
25
18
11
4
Th
26
19
12
5
Th
25
18
11
4
F
26
19
12
5
F
26
19
12
5
F
27
20
13
6
F
26
19
12
5
Sa
27
20
13
6
Sa
27
20
13
6
Sa
28
21
14
7
Sa
_________________________________________
_________________________________________
F
_________________________________________
_________________________________________
Th
_________________________________________
_________________________________________
W
_________________________________________
_________________________________________
Sa
_________________________________________
_________________________________________
F
_________________________________________
_________________________________________
Th
_________________________________________
_________________________________________
Sa
_________________________________________
_________________________________________
F
_________________________________________
_________________________________________
June 2014
_________________________________________
_________________________________________
May 2014
_________________________________________
_________________________________________
April 2014
_________________________________________
_________________________________________
March 2014
_________________________________________
_________________________________________
2014
Phone Numbers
Important Dates
16
9
2
Thursday
17
10
3
Easter
27
First day of Spring
28
21
29
22
30
23
31
24
15
8
1
Wednesday
20
14
13
Tuesday
St. Patrick’s Day
7
6
Monday
Daylight Saving Time begins
Sunday
January 2015
25
18
11
4
Good Friday
Friday
Saturday
26
19
12
5
Sunday
19
18
25
12
11
26
Martin Luther King, Jr. Day
5
4
Monday
March 2016
Tuesday
27
20
13
6
7
28
21
14
Wednesday
1
29
22
15
8
New Year’s Day
Thursday
Friday
30
23
16
9
2
Saturday
31
24
17
10
3
14
7
8
1
22
29
28
Presidents Day
15
Chinese New Year
Monday
21
Valentine’s Day
Sunday
Tuesday
February 2015
23
16
9
2
3
24
17
10
Wednesday
Thursday
25
18
11
4
Friday
26
19
12
5
Saturday
27
20
13
6
Sunday
16
15
22
9
8
23
Presidents Day
2
1
Monday
Tuesday
February 2016
24
17
10
3
4
25
18
11
Wednesday
19
12
5
26
Chinese New Year
Thursday
Friday
27
20
13
6
14
7
28
21
Valentine’s Day
Saturday
24
Sunday
18
17
31
11
10
25
Martin Luther King, Jr. Day
4
3
Monday
March 2015
Tuesday
26
19
12
5
6
27
20
13
Wednesday
Thursday
28
21
14
7
1
29
22
15
8
New Year’s Day
Friday
Saturday
30
23
16
9
2
2
9
8
Monday
1
16
23
30
15
22
29
Daylight Saving Time begins
Sunday
January 2016
17
10
3
31
24
St. Patrick’s Day
Tuesday
4
25
18
11
Wednesday
Thursday
26
19
12
5
20
13
6
27
First day of Spring
Friday
Saturday
28
21
14
7
Sunday
14
21
28
20
27
First day of Hanukkah
7
13
6
Monday
April 2015
22
15
8
1
29
First day of Winter
Tuesday
9
2
30
23
16
Wednesday
Thursday
31
24
17
10
3
25
18
11
4
Christmas Day
Friday
26
19
12
5
First day of Kwanzaa
Saturday
Sunday
13
20
27
19
26
6
12
Easter
5
Monday
Tuesday
December 2015
28
21
14
7
8
1
29
Earth Day
22
15
Wednesday
Thursday
30
23
16
9
2
3
24
17
10
Good Friday
Friday
4
25
18
11
First day of Passover
Saturday
1
16
23
30
15
22
29
2
9
Monday
8
Daylight Saving Time ends
Sunday
May 2015
Tuesday
24
17
10
3
4
25
18
Veterans Day
11
Wednesday
26
19
12
5
Thanksgiving
Thursday
Friday
27
20
13
6
Saturday
28
21
14
7
24
11
10
31
17
Memorial Day
25
18
4
Monday
3
Mother’s Day
Sunday
Tuesday
November 2015
26
19
12
5
6
27
20
13
Wednesday
Thursday
28
21
14
7
Friday
29
22
15
8
1
Saturday
30
23
16
9
2
Sunday
12
11
19
26
18
25
Columbus Day
5
4
Monday
June 2015
Tuesday
27
20
13
6
7
28
21
14
Wednesday
Thursday
29
22
15
8
1
Friday
30
23
16
9
2
31
24
17
10
3
Halloween
Saturday
18
11
4
28
Father’s Day
29
22
30
23
24
25
17
10
3
Thursday
21
16
9
2
Wednesday
Ramadan begins
Tuesday
Flag Day
15
14
1
8
Monday
7
First day of Summer
Sunday
October 2015
Friday
26
19
12
5
Saturday
27
20
13
6
Sunday
21
28
27
Rosh Hashanah
14
Labor Day
7
20
13
6
Monday
July 2015
Tuesday
29
22
15
8
1
9
2
30
First day of Fall
Yom Kippur
23
16
Wednesday
Thursday
24
17
10
3
Friday
25
18
11
4
Saturday
26
19
12
5
Sunday
6
13
20
27
5
12
19
26
Monday
Tuesday
September 2015
28
21
14
7
8
1
29
22
15
Wednesday
Thursday
30
23
16
9
2
Friday
31
24
17
10
3
4
25
18
11
Independence Day
Saturday
23
Sunday
31
17
16
30
10
9
24
3
2
Monday
August 2015
Tuesday
25
18
11
4
5
26
19
12
Wednesday
Thursday
27
20
13
6
Friday
28
21
14
7
Saturday
29
22
15
8
1
| File Type | application/pdf |
| File Modified | 2014-10-01 |
| File Created | 2014-10-01 |