NEW PATIENT INTAKE FORMS PEDIATRIC - Amy Myers MD · PDF file1 AMY MYERS, MD Austin UltraHealth Westlake Medical Center 5656 Bee Cave Road Suite D-203 Austin, Texas 78746 Phone: 512-383-5343

1

AMY MYERS, MD Austin UltraHealth

Westlake Medical Center 5656 Bee Cave Road Suite D-203

Austin, Texas 78746 Phone: 512-383-5343

Fax: 512-721-0348

NEW PATIENT INTAKE FORMS

PEDIATRIC For ages 0-13 years

THESE FORMS MUST BE SUBMITTED TO OUR OFFICE AT LEAST 7 DAYS PRIOR

TO YOUR FIRST APPOINTMENT

Due to sensitivities, our office is fragrance free. We ask that you DO NOT wear scented products to our office. This includes perfumes, colognes, lotions, deodorants, soaps and shampoos.

4""

5-%-0*+"(%#)0,*'()%"".%/'0$ ./012# 3/4456# $712""1#'2'##'3$.%/'0"

"4%5'$"2$67#580$ 9&'0"":';3'#0$ ! ,678" ! #89678"

:';'57<$6%<=&#">;30$ ! *:;<=6>" ! -?;@A86>" ! %6B<C8"*98;<=6>" ! ,8D<B8;;6>86>"" ! *E<6>" ! *EFG8>6H<" ! ,<DD78"-6EB8;>"356789%:8;<=5>?9@%>A?7%BC57>?899D?65%?"58'#@($.%/'$ )==?A6B<@>$!%58'#@($.%/'$ )==?A6B<@>$

1#7/%#-$933#'((0$%$>655>% % 0<>E%48E%$/?>F% $>D>5% G?<"

9A5'#;%5'$933#'((0$%$>655>% % 0<>E%48E%$/?>F% $>D>5% G?<"

B"/'$18";'$+0$B"/'$18";'$C0$1%#';5@($D"#=$18";'0$$1%#';5@($E'AA$18";'0$$!%F0$G*/%7A0$$

G/'#&';<-$E";5%<50$$4D;5% % 3A895%%0HH6577% % % 0<>E%48E"%/?>F% $>D>5% G?<""

18-(7<7%;@($.%/'I"%/F@>8" #6J""

08:8;;8D"KLI""! 5@@M78"NA786E8"7<EB"BF8"E86;=F"O@;DE"L@?"?E8D"B@":<>D"?EP" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ "! ,8D<6"NA786E8"<>D<=6B8"E@?;=8P"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""! #69<7L",89K8;"NA786E8"7<EBP"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""! #;<8>D"NA786E8"7<EBP"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""! )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""

R""

/S*0,*&T"(%#)0,*'()%"1#7/%#-$18%#/%<-0$4D;5% % 3A895%%0HH6577"%/?>F% $>D>5% G?<""#I;D?=% % &DJK%# 8#,2#/1#69206:65;#/:<=027>2#2?72#;=@#5/12#2?6#<?70:7A;B1#C79#>@:D60E#

E"/H">;37;&IJ>HHA'/';5$18%#/%<-0"4D;5% % 3A895%%0HH6577"%/?>F% $>D>5% G?<""#I;D?=% % &DJK%# 8#,2#/1#69206:65;#/:<=027>2#2?72#;=@#5/12#2?6#<?70:7A;B1#C79#>@:D60E#

U""

1G4K9LMKE$?G4KE9N$OPGJLKQ..9KMG$"*++-05(-3",8D<=6B<@>V3?AA7898>BV#@@D" 086=B<@>_________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________

&),/+*(%'3V&)%&-0%3"1F6B"D@"L@?"F@A8"B@"6=F<8C8"<>"L@?;"C<E<B"O<BF"?EW ________________________________________________________________________________________________________________________________________________________ (:"L@?"F6D"6"96M<="O6>D"6>D"=@?7D"F87A"L@?;"=F<7D"<>"BF;88"O6LEX"OF6B"O@?7D"BF8L"K8W"

!Y QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"4Y QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"RY QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

1F8>"O6E"BF8"76EB"B<98"L@?":887"L@?;"=F<7D"O6E"O877W ________________________________________________________________________________________________________________________________________________________ ".<D"E@98BF<>M"B;<MM8;"L@?;"=F<7DZE"=F6>M8"<>"F867BFW ________________________________________________________________________________________________________________________________________________________ "(E"BF8;8"6>LBF<>M"BF6B"96G8E"L@?;"=F<7D":887"O@;E8 ________________________________________________________________________________________________________________________________________________________ "(E"BF8;8"6>LBF<>M"BF6B"96G8E"L@?;"=F<7D":887"K8BB8;W ________________________________________________________________________________________________________________________________________________________ "/786E8"7<EB"=?;;8>B"6>D"@>M@<>M"A;@K789E"<>"@;D8;"@:"A;<@;<BLI"

4'(<#7R'$1#"RA'/$

?7A3$

?"3'#%5'$

J'S'#'$ 1#7"#$L#'%5/';5I9HH#"%<8$

GF<'AA';5$

:""3$

!%7#$

"#JD;<=5L%-?MM?:C=>F%)D?9>D?9?9@%0>>59>?89%

" N% " #=?;?9D>?89%-?5>% N% " "

" " " " " " " "" " " " " " " "" " " " " " " "" " " " " " " "" " " " " " " "" " " " " " " "" " " " " " " "

[""

,-.(&*+"S(3')0T".(3-*3-3V".(*5%)3(3V"&)%.('()%3"/A5:O%D<<68<6?D>5%P8J%D9H%<68Q?H5%HD>5%8M%8975>%

/6EB" &?;;8>B" :9JLMQK.LGJLK.9N$ /6EB" &?;;8>B" ?PJEPNQJTGNGL9NI$19K.$UE";5VW$"" "" (;;<B6K78"\@O87"3L>D;@98"QQQQQQQQQQQQQQQQQ" "" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" (>:76996B@;L"\@O87".<E86E8"QQQQQQQQQQQQQQQ" /6EB" &?;;8>B" K.!N9??9LKQ.I$9PLQK??P.G$"" "" &;@F>ZE"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" &F;@><="#6B<M?8"3L>D;@98"QQQQQQQQQQQQQQQQQ"

"" "" $7=8;6B<C8"&@7<B<E"QQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" *?B@<99?>8".<E86E8"QQQQQQQQQQQQQQQQQQQQQQ"

"" "" 56EB;<B<E"@;"/8AB<="$7=8;".<E86E8"QQQQQQQQQQQQ" "" "" 0F8?96B@<D"*;BF;<B<E"QQQQQQQQQQQQQQQQQQQQQQ"

"" "" 5-0."N;8:7?JP"QQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" +?A?E"3+-"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" &87<6=".<E86E8"QQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" (99?>8".8:<=<8>=L".<E86E8"QQQQQQQQQQQQQQQQ"

"" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" 38C8;8"(>:8=B<@?E".<E86E8"QQQQQQQQQQQQQQQQQQQ"/6EB" &?;;8>B" E9M4KQX9JEPN9M$ "" "" /@@;"(99?>8"#?>=B<@>"QQQQQQQQQQQQQQQQQQQQ"

"" "" S86;B".<E86E8"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" N:;8]?8>B"<>:8=B<@>P"

"" "" -78C6B8D"&F@78EB8;@7"QQQQQQQQQQQQQQQQQQQQQQ" "" "" #@@D"*778;M<8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" SLA8;B8>E<@>"NF<MF"K7@@D"A;8EE?;8P"QQQQQQQQQ" "" "" ->C<;@>98>B67"*778;M<8E"QQQQQQQQQQQQQQQQQQQ"

"" "" 0F8?96B<="#8C8;"QQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" ,?7B<A78"&F89<=67"38>E<B<C<B<8E"QQQQQQQQQQQQQQ"

"" "" ,<B;67"^67C8"/;@76AE8"QQQQQQQQQQQQQQQQQQQQQ" "" "" +6B8J"*778;ML"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"/6EB" &?;;8>B" ?GL96QNKEI$G.4QEMK.G$ /6EB" &?;;8>B" MGJ1KM9LQMY$4KJG9JGJ$"" "" 'LA8"!".<6K8B8E"QQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" #;8]?8>B"-6;"(>:8=B<@>E"QQQQQQQQQQQQQQQQQQQQ"

"" "" 'LA8"4".<6K8B8E"QQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" #;8]?8>B"$AA8;"08EA<;6B@;L"(>:8=B<@>E"QQQQQQQ"

"" "" SLA@M7L=89<6"QQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" *EBF96"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" ,8B6K@7<="3L>D;@98"N/;8_.<6K8B8EP"QQQQQQQQ" "" "" &F;@><="3<>?E<B<E"QQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" SLA@BFL;@<D<E9"N7@O"BFL;@<DP"QQQQQQQQQQQQQ" "" "" \;@>=F<B<E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" SLA8;BFL;@<D<E9"N@C8;6=B<C8"BFL;@<DP"QQQQQQQ" "" "" 3788A"*A>86"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" ->D@=;<>8"/;@K789E"QQQQQQQQQQQQQQQQQQQQQQ" "" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" /@7L=LEB<=")C6;<6>"3L>D;@9"N/&)3P"QQQQQQQQ" /6EB" &?;;8>B" JTK.$4KJG9JGJ$"" "" 18<MFB"56<>"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" -=H896"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" 18<MFB"+@EE"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" /E@;<6E<E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" #;8]?8>B"18<MFB"#7?=B?6B<@>E"QQQQQQQQQQQQQ" "" "" *=>8"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" \?7<9<6"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" *>@;8J<6"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" /6EB" &?;;8>B" .GPMQNQ:KEI$?QQ4$"" "" \<>M8"-6B<>M".<E@;D8;"QQQQQQQQQQQQQQQQQQQQQ" "" "" .8A;8EE<@>"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" %<MFB"-6B<>M"3L>D;@98"QQQQQQQQQQQQQQQQQQQ" "" "" *>J<8BL"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" -6B<>M".<E@;D8;"N>@>_EA8=<:<=P"QQQQQQQQQQQQQ" "" "" \<A@76;".<E@;D8;"QQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" 3=F<H@AF;8><6"QQQQQQQQQQQQQQQQQQQQQQQQQQQ"/6EB" &?;;8>B" E9.EGM$ "" "" S86D6=F8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" ,<M;6>8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"/6EB" &?;;8>B" :G.KL9N$9.4$PMK.9MY$JYJLG?J$ "" "" *..V"*.S."QQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" 2<D>8L"3B@>8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" 38>E@;L"(>B8M;6B<C8".<E@;D8;"QQQQQQQQQQQQQQQQ"

"" "" $;<>6;L"';6=B"(>:8=B<@>"QQQQQQQQQQQQQQQQQQQ" "" "" *?B<E9"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" T86EB"(>:8=B<@>E"QQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" ,<7D"&@M><B<C8"(9A6<;98>B"QQQQQQQQQQQQQQQQQ"

"" "" )BF8;"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" *+3"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"/6EB" &?;;8>B" ?PJEPNQJTGNGL9NI$19K.$ "" "" 38<H?;8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" *;BF;<B<E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" *;BF;<B<E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" "" #<K;@9L67M<6"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" "" )BF8;"%8?;@7@M<=67"/;@K789E"QQQQQQQQQQQQQQQ"

"" "" &F;@><="/6<>"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ" " " "

`""

,-.(&*+"S(3')0T"N&)%'(%$-.P"$ $1MGXKQPJ$GX9NP9LKQ.J$ K.ZPMKGJ"/A5:O%P8J%?M%F57%D9H%<68Q?H5%HD>5% /A5:O%P8J%?M%F57%D9H%<68Q?H5%HD>5"

"" #?77"/FLE<=67"-J69"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"

"" \6=G"(>a?;L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" /EL=F@7@M<=67"-C67?6B<@>EQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" %8=G"(>a?;L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 18=FE78;"/;8E=F@@7"b"/;<96;L"" "" S86D"(>a?;L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 3=678"@:"(>B877<M8>=8"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" \;@G8>"\@>8E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 3A88=F"6>D"+6>M?6M8"-C67?6B<@>E"QQQQQQQQQQQQQQQQQQQ" "" )BF8;""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 58>8B<="-C67?6B<@>"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" S86D"(>a?;L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" %8?;@7@M<=67"-C67?6B<@>E""QQQQQQQQQQQQQQQQQQQQQQQQQQ" "" \;@G8>"\@>8E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 56EB;@8>B8;@7@ML"-C67?6B<@>E""QQQQQQQQQQQQQQQQQQQQQQ" "" )BF8;""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" &87<6=V57?B8>"B8EB<>M""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" JPM:GMKGJ$"" *778;ML"-C67?6B<@>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" /A5:O%P8J%?M%F57%D9H%<68Q?H5%HD>5"

"" %?B;<B<@>67"-C67?6B<@>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" *AA8>D8=B@9L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" *?D<B@;L"-C67?6B<@>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" &<;=?9=<E<@>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" ^<E<@>"-C67?6B<@>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" S8;><6""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" )EB8@A6BF<=""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" '@>E<7E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" *=?A?>=B?;8""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" *D8>@<DE""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" )==?A6B<@>67"'F8;6AL""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" .8>B67"3?;M8;L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 38>E@;L"(>B8M;6B<@>"'F8;6AL""QQQQQQQQQQQQQQQQQQQQQQQ" "" '?K8E"<>"-6;E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" +6>M?6M8"&76EE8E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" "" )BF8;""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" 3<M>"+6>M?6M8""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" 6NQQ4$LY1G0$ !"*" !"\" !"*\" !")" !"0Fc" !"$>G>@O>$"" S@98@A6BF<=""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" %6B?;@A6BF<=""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" &;6><@E6=;67""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" &F<;@A;6=B<=""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" ,0(""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" &'"3=6>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" $AA8;"->D@E=@AL""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" $AA8;"5("38;<8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

"" $7B;6E@?>D"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

$

BQJ1KL9NK[9LKQ.J$"$%@>8""""(:"L8EX"A786E8"7<EBI"

.6B8" 086E@>"

" "

" "

" "

" "

" "

$

d""

,-.(&*+"S(3')0T"N&)%'(%$-.P"K??P.K[9LKQ.J$(E"L@?;"=F<7D"?A"B@"D6B8"O<BF"<99?><H6B<@>EW" eeeeeeeeeeeeeeeeeeeeeeeeeY" ! T8E" ! %@".@"L@?":887"<99?><H6B<@>E"F6C8"F6D"6>"<9A6=B"@>"L@?;"=F<7DZE"F867BFW" eeeeeeeeeeY" ! T8E" ! %@"(:";878C6>BX"6BB6=F"6"=@AL"@:"L@?;"=F<7DZE"<99?><H6B<@>";8=@;D"@;"E88"6DD8>D?9Y""1JYEBQJQEK9N$S6E"L@?;"=F<7D"8JA8;<8>=8D"6>L"96a@;"7<:8"=F6>M8E"BF6B"96L"F6C8"<9A6=B8D"F<EVF8;"F867BFW" eYeeeeeeeeYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY" ! T8E" ! %@"S6E"L@?;"=F<7D"8C8;"8JA8;<8>=8D"6>L"96a@;"7@EE8EW" eeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@""JLMGJJIEQ1K.:$S6C8"L@?"8C8;"E@?MFB"=@?>E87<>M":@;"L@?;"=F<7DW" eeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"(E"L@?;"=F<7D"@;":69<7L"=?;;8>B7L"<>"BF8;6ALW" eeeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"" .8E=;<K8I"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ".@8E"L@?;"=F<7D"F6C8"6":6C@;<B8"B@L"@;"@Ka8=BW" eeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"&F8=G"677"BF6B"6AA7LI"" " T@M6" " ,8D<B6B<@>" " (96M8;L" " \;86BF<>M"" " '6<"&F<" " /;6L8;" " )BF8;"NA786E8"D8E=;<K8P" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""S6E"L@?;"=F<7D"8C8;"K88>"6K?E8DX"6"C<=B<9"@:"6"=;<98X"@;"8JA8;<8>=8D"6"E<M><:<=6>B"B;6?96W""eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@""JNGG1IMGJL$*C8;6M8">?9K8;"@:"F@?;E"L@?;"=F<7D"E788AE"6B"><MFBI" ! f!4" ! !g_!4" ! h_!g" ! ih".@8E"L@?;"=F<7D"F6C8"B;@?K78":677<>M"6E788AW""eeeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@".@8E"L@?;"=F<7D":887";8EB8D"?A@>"6O6G8><>MW"" eeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@".@8E"L@?;"=F<7D"E>@;8W""eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@""MQNGJIMGN9LKQ.JBK1$1?7>%&D;?=F%)5;P567L%#69<7L",89K8;"6>D"0876B<@>EF<A" *M8" 58>D8;"$ $ $$ $ $$ $ $$ $ $$ $ $$1F@"6;8"BF8"96<>"A8@A78"OF@"=6;8":@;"L@?;"=F<7DW"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"'F8<;"-9A7@L98>BV)==?A6B<@>I" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"08E@?;=8E":@;"89@B<@>67"E?AA@;BW"/A5:O%D==%>AD>%D<<=FL"" 3A@?E8" " #69<7L" " #;<8>DE" " 087<M<@?EV3A<;<B?67"" /8BE" " )BF8;"NA786E8"7<EBP"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""

h""

5T%-&)+)5(&"S(3')0T"NM86%R8;59%89=FP""?G.JLMP9N$BKJLQMY$*M8"6B":<;EB"A8;<@DI"QQQQQQQQQQQQQQQQ" ,8>E8E"#;8]?8>=LI"QQQQQQQQQQQQQQQ" +8>MBFI"QQQQQQQQQQQQQQQQ"/6<>I""eeeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@"&7@BB<>MI"" eeeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@"S6E"L@?;"A8;<@D"8C8;"EG<AA8DW""eeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@"#@;"F@O"7@>MW"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"+6EB",8>EB;?67"/8;<@DI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"$E8"@:"F@;9@>67"=@>B;6=8AB<@>"E?=F"6EI" " \<;BF"&@>B;@7"/<77E" " /6B=F"" " %?C6"0<>M"S@O"7@>MW"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ".@"L@?"?E8"=@>B;6=8AB<@>W"" eeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@"(:"L8EX"OF<=F"BLA8W" " &@>D@9" " .<6AF;6M9" " ($." " /6;B>8;"^6E8=B@9L"5("S(3')0T""S6E"L@?;"=F<7D"B;6C878D"B@":@;8<M>"=@?>B;<8EW" eeYYeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"(:"L8EX"OF8;8WQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"1<7D8;>8EE"&69A<>MW"" eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYYY" ! T8E" ! %@"(:"L8EX"OF8;8WQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-C8;"F6D"E8C8;8I"" " 56EB;@8>B8;<B<E" " .<6;;F86".-%'*+"S(3')0T"" 3<7C8;",8;=?;L"#<77<>ME"(:"L8EX"F@O"96>LW"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"" 5@7D"#<77<>ME" " 0@@B"&6>67E" " (9A76>BE" " '@@BF"/6<>"" \788D<>M"5?9E" " 5<>M<C<B<E" " /;@K789E"O<BF"&F8O<>M".@"L@?":7@EE";8M?76;7LW" eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"/*'(-%'"\(0'S"S(3')0T"?QLBGM@J$19JL$1MG:.9.EKGJ$%?9K8;"@:I" /;8M>6>=<8E"QQQQQQQQQ" +<C8"K<;BFEI"QQQQQQQQQQ" ,<E=6;;<6M8EI"QQQQQQQQQQQQ"?QLBGM@J$1MG:.9.EY$/A5:O%P8J%?M%F57%D9H%<68Q?H5%HD>5%# " .<::<=?7BL"M8BB<>M"A;8M>6>B"N9@;8"BF6>"`"9@>BFEP"QQQQQ" # "5;@?A"\"EB8A"<>:8=B<@>"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"# " (>:8;B<7<BL"D;?ME"?E8D"3A8=<:LI"QQQQQQQQQQQQQQQQQQQQQQQ" # "S6C8"=_E8=B<@>"K8=6?E8"@:"QQQQQQQQQQQQQQQQQQQQQQQQQQQ"# " (>"C<B;@":8;B<7<H6B<@>"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" # "$E8"<>D?=B<@>":@;"76K@;"NE?=F"6E"/<B@=<>PQQQQQQQQQQQQQQQ"# " .;<>G"67=@F@7"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" # "S6C8"6>68EBF8E<6"j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

k""

/*'(-%'"\(0'S"S(3')0T"N&)%'(%$-.P$"/0-5%*%&T"'@B67"O8<MFB"M6<>"D?;<>M"A;8M>6>=LI"QQQQQQQQQ"7KEY" '@B67"O8<MFB"7@EE"D?;<>M"A;8M>6>=LI"QQQQQQQQQ"7KEY"/786E8"D8E=;<K8"D<8B"D?;<>M"A;8M>6>=LI ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ /786E8"D8E=;<K8"76K@;I ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ $1GMK.9L9N$/;8M>6>=L"D?;6B<@>I"N%M8==8R?9@%>A5%R55O%8M%@57>D>?89%! 24 ! 25 ! 26 ! 27 ! 28 ! 29 ! 30 ! 31 ! 32 ! 33 ! 34 ! 35 ! 36 ! 37 ! 38 ! 39 ! 40 (full term) ! 41 ! 42 ! 43 ! 44 Weeks ^8;L"6=B<C8"K8:@;8"K<;BFW"" eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"S@EA<B67V\<;BF<>M"&8>B8;W"" eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeYeeYYY" ! T8E" ! %@"%88D8D"%8OK@;>"3A8=<67"&6;8W""eeeYeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"*AA86;8D"F867BFLW""eeeeeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"-6E<7L"=@>E@78D"D?;<>M":<;EB"9@>BFW""eeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"*>B<K<@B<=E":<;EB"9@>BFW""eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"-JA8;<8>=8D">@"=@9A7<=6B<@>E":<;EB"9@>BF"@:"7<:8W"eeeeeeeeeeeYYeeeeeeeeeeeYYY" ! T8E" ! %@""6KMLB$DGK:BL$9.4$91:9M$

18<MFB"6B"K<;BFI"QQQQQQQQ"7KE"""""""*AM6;"E=@;8"6B"@>8"9<>?B8I"QQQQQQQQ"""""*AM6;"E=@;8"6B"["9<>EI"QQQQQQQQ"

"G9MNY$EBKN4BQQ4$KNN.GJJGJ$

%?9K8;"@:"86;6=F8E"<>"BF8":<;EB"BO@"L86;EI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"%?9K8;"@:"@BF8;"<>:8=B<@>E"<>"BF8":<;EB"BO@"L86;EI"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"%?9K8;"@:"B<98E"L@?"F6D"6>B<K<@B<=E"<>"BF8":<;EB"BO@"L86;E"@:"7<:8I""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"%?9K8;"@:"=@?;E8E"@:"A;@AFL76=B<="6>B<K<@B<=E"<>":<;EB"4"L86;E"@:"7<:8I""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"#<;EB"6>B<K<@B<="6B"QQQQQQQQQ"9@>BFEY"#<;EB"<77>8EE"6B"QQQQQQQQQ"9@>BFEY""4GJEMK1LKQ.$Q!$4GXGNQ1?G.L9N$1MQ6NG?J$

(:"L@?;"=F<7D"F6E"D8C87@A98>B67"A;@K789EX"6B"OF6B"6M8"D<D"BF8L"@==?;W"! 0-1 months" ! 2-6 months" ! 6-15 months" ! 16-24 months" ! After 24 months (E"BF<E"<9A;8EE<@>"EF6;8D"69@>M"A6;8>BE"6>D"@BF8;E"=6;<>M":@;"BF8"=F<7DW"eeeeeeeeeeeYYY"! T8E" ! %@".@8E"BF<E"<9A;8EE<@>X"6E"BF8"B<9<>M"@:"@>E8BX"D<::8;"69@>M"A6;8>BE"6>D"@BF8;E"=6;<>M":@;"BF8"=F<7DW""eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"(E"BF8"<9A;8EE<@>X"6E"B@"BF8"B<9<>M"@:"@>E8BX"O86GW"eeeeeeeeeeeeeeeeeeeeeeeeYYY"! T8E" ! %@");"<E"BF<E"<9A;8EE<@>"EB;@>MW"" eeeeeeeeeeeYYeeeeeeeeeeeYeeeeeeeeeeeeYYY" ! T8E" ! %@"

!g""

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

!!""

,-.(&*'()%3$EPMMG.L$?G4KE9LKQ.J$

Medications Dose Frequency Start Date (month/year) Reason For Use PREVIOUS MEDICATIONS: Last 10 years

Medications Dose Frequency Start Date (month/year) Reason For Use NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY) Supplication and Brand Dose Frequency Start Date (month/year) Reason For Use "S6C8"L@?;"98D<=6B<@>E"@;"E?AA7898>BE"8C8;"=6?E8D"L@?"?>?E?67"E<D8"8::8=BE"@;"A;@K789EW" ! T8E" ! %@"" .8E=;<K8I"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"S6C8"L@?"F6D"A;@7@>M8D"@;";8M?76;"?E8"@:"%3*(.3"N8YMYX"*DC<7X"*78C8PX",@B;<>X"*EA<;<>W"YYYY" ! T8E" ! %@"S6C8"L@?"F6D"A;@7@>M8D"@;";8M?76;"?E8"@:"'L78>@7""eYeeeeeeeeeeYYeeeeeeeeeeYYYY" ! T8E" ! %@"S6C8"L@?"F6D"A;@7@>M8D"@;";8M?76;"?E8"@:"*=<D"\7@=G<>M".;?ME"N8YMYX"'6M698BX"l6>B6=X"/;<7@E8=P"eeeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeeeeeeeeeYYYe" ! T8E" ! %@"#;8]?8>B"6>B<K<@B<=E"f"R"B<98EVL86;"eeeYYeeeeeeeeeeYYeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@"+@>M"B8;9"6>B<K<@B<=E" eeeYYeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"$E8"@:"EB8;@<DE"NA;8D><E@>8X">6E67"6778;ML"<>F678;EP"<>"BF8"A6EB"eeeYeeeeeeeeeeeeYYY" ! T8E" ! %@"$E8"@:"@;67"=@>B;6=8AB<C8E" eeeeeeeeeeeYYeeeeeeeeeeeYeeeeeeeeeeeeeYYYY" ! T8E" ! %@"

!4""

#*,(+T"S(3')0T$

/A5:O%MD;?=F%;5;P567%>AD>%D<<=F%

,@B

F8;"

#6BF

8;"

\;@B

F8;N

EP"

3<EB

8;NE

P"

&F<

7D;8

>"

,6B

8;>6

7"5

;6>D

9@B

F8;"

,6B

8;>6

7"5

;6>D

:6BF

8;"

/6B8

;>67

"5

;6>D

9@B

F8;"

/6B8

;>67

"5

;6>D

:6BF

8;"

*?>

BE"

$>=

78E"

)BF

8;"

*M8"N<:"EB<77"67<C8P" " " " " " " " " " " " "*M8"6B"D86BF"N<:"D<E86E8DP" " " " " " " " " " " " "&6>=8;E" " " " " " " " " " " " "&@7@>"&6>=8;" " " " " " " " " " " " "\;86EB"@;")C6;<6>"&6>=8;" " " " " " " " " " " " "S86;B".<E86E8" " " " " " " " " " " " "SLA8;B8>E<@>" " " " " " " " " " " " ")K8E<BL" " " " " " " " " " " " ".<6K8B8E" " " " " " " " " " " " "3B;@G8" " " " " " " " " " " " "(>:76996B@;L"*;BF;<B<E"N0F8?96B@<DX"/E@;<6B<=X"*>GL7@E<>M"3@>DL7<B<EP"

" " " " " " " " " " " "

(>:76996B@;L"\@O87".<E86E8" " " " " " " " " " " " ",?7B<A78"3=78;@E<E" " " " " " " " " " " " "*?B@"(99?>8".<E86E8E"NE?=F"6E"+?A?EP" " " " " " " " " " " " "(;;<B6K78"\@O87"3L>D;@98" " " " " " " " " " " " "&87<6=".<E86E8" " " " " " " " " " " " "*EBF96" " " " " " " " " " " " "-=H896V/E@;<6E<E" " " " " " " " " " " " "#@@D"*778;M<8EX"38>E<B<C<B<8E"@;"(>B@78;6>=8E" " " " " " " " " " " " "->C<;@>98>B67"38>E<B<C<B<8E" " " " " " " " " " " " ".898>B<6" " " " " " " " " " " " "/6;G<>E@>ZE" " " " " " " " " " " " "*+3"@;"@BF8;",@B@;"%8?;@>".<E86E8E" " " " " " " " " " " " "58>8B<=".<E@;D8;E" " " " " " " " " " " " "3?KEB6>=8"*K?E8"NE?=F"6E"67=@F@7<E9P" " " " " " " " " " " " "/EL=F<6B;<=".<E@;D8;E" " " " " " " " " " " " ".8A;8EE<@>" " " " " " " " " " " " "3=F<H@AF;8><6" " " " " " " " " " " " "*.S." " " " " " " " " " " " "*?B<E9" " " " " " " " " " " " "\<A@76;".<E86E8" " " " " " " " " " " " "

"

!R""

%$'0('()%"S(3')0T$"S6E"L@?;"=F<7D"8C8;"F6D"6">?B;<B<@>"=@>E?7B6B<@>W""eYeeeeeeeeeeYYeeeeeeeeeeYYYY" ! T8E" ! %@"S6C8"L@?"96D8"6>L"=F6>M8E"<>"L@?;"=F<7DZE"D<8B"K8=6?E8"@:"F867BF"A;@K789EW"eYeeeeeYYYY"! T8E" ! %@"" .8E=;<K8""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ".@8E"L@?;"=F<7D":@77@O"6"EA8=<67"D<8B"@;">?B;<B<@>67"A;@M;69W"eeeYeeeeeeeeeeeYeYYYY" ! T8E" ! %@"/A5:O%D==%>AD>%D<<=F%" .6<;L"#;88" " .<6K8B<=" " #8<>M@7D" " 57?B8>"08EB;<=B8D"" 57?B8>V&6E8<>"#;88" " 28B@M8><=" " +@O")J676B8" " 3A8=<:<="&6;K@FLD;6B8"" ^8M6>" " ^8M8B6;<6>" " 18<MFB",6>6M898>B" " 1F86B"#;88"" T86EB"#;88" " #@@D"*778;ML"N8YMYX%<5D9C>7W%5@@7VL"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""S8<MFB"N:88BV<>=F8EP""QQQQQQQQQQQQQQQQQQQQQQQQQQQ" &?;;8>B"18<MFB"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"+@>M8EB"18<MFB"#7?=B?6B<@>E"eeeYY" ! T8E" ! %@" "".@8E"L@?;"=F<7D"6C@<D"6>L"A6;B<=?76;":@@DEW"eeeYeeeeeeeeeeeYeeeeeeeeeeeeYY" ! T8E" ! %@"" (:"L8EX"BLA8E"6>D";86E@>I ________________________________________________________________________________________________________________________________________________________

(:"L@?;"=F<7D"=@?7D"86B"@>7L"6":8O":@@DE"D6<7LX"OF6B"O@?7D"BF8L"K8W ________________________________________________________________________________________________________________________________________________________

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a?<=8"<>B6G8"# %-6B"9@;8"BF6>"[gm"9867E"6O6L":;@9"F@98" # "+@O":;?<BVC8M8B6K78"<>B6G8"# %/@@;"E>6=G"=F@<=8E" # "S<MF"E?M6;VEO88B"<>B6G8"# %38>E@;L"<EE?8E"O<BF":@@D" # "58EB6B<@>67"

"# %/<=GL"86B8;" # "S<MF"K7@@D"A;8EE?;8NA;8_

"# %+<9<B8D"C6;<8BL"@:":@@DE"i"[VD6L" # "S<MF"K7@@D"

"# %/;8:8;E"=@7D":@@D" # "S6C8"=F89<=67"8JA@E?;8"

"# "/;8:8;E"F@B":@@D"# "-C8;L"9867"<E"6"EB;?MM78"

"\0-*3'#-."S(3')0T"\;86EB:8DW" eYeeeeeeeeeeeeeeeeeeeeeeeeeeeYeeeeeeYYeeeeeeeeeeYYYY" ! T8E" ! %@"'LA8"@:":@;9?76I" " 3@L" " &@OZE",<7G" " +@O"*778;ML"(>B;@D?=B<@>"@:"=@OZE"9<7G"6B"QQQQQQQQQQ"9@>BFEY" (>B;@D?=B<@>"@:"E@7<D":@@DE"6B"QQQQQQQQQQQ"9@>BFEY"#<;EB":@@DE"<>B;@D?=8D"6B"QQQQQQQQQ"9@>BFEY" (>B;@D?=B<@>"@:"OF86B"@;"@BF8;"M;6<>"6B"QQQQQQQQQQ"9@>BFEY

!U""

%$'0('()%"S(3')0T"N&)%'(%$-.P$\0-*3'#-."S(3')0TX"N&@>BYP"&F@G8V56EV^@9<B"@>"9<7GW""eYeeeeeeeeeeeeeeeeeYeeeeeeYYeeeeeeeeeeYYYY" ! T8E" ! %@"08:?E8D"B@"=F8O"E@7<DEW""eYeeeeeeeeeeeeeeeeeeeeeeeeeeeYeeeeeeYYeeYYYY" ! T8E" ! %@"+<EB"9@BF8;ZE"G>@O>":@@D"6778;M<8E"@;"E8>E<B<C<B<8EI ________________________________________________________________________________________________________________________________________________________ "/786E8"D8E=;<K8"6>L"@BF8;"86B<>M"=@>=8;>E"L@?"F6C8";8M6;D8D"O<BF"L@?;"=F<7DI ________________________________________________________________________________________________________________________________________________________ *&'(^('T$1?7>%>F<5%D9H%D;8C9>%8M%D:>?Q?>F%HD?=FE%'LA8" *9@?>B".6<7L_________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________

S@O"9?=F"B<98"D@8E"L@?;"=F<7D"EA8>D"O6B=F<>M"'^W"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"S@O"9?=F"B<98"D@8E"L@?;"=F<7D"EA8>D"@>"BF8"=@9A?B8;"@;"A76L<>M"C<D8@"M698EW"QQQQQQQQQQQQQQQQQQQQQQ""

-%^(0)%,-%'*+"S(3')0T$3=5D75%:A5:O%D<<68<6?D>5%P8JE%/6EB" &?;;8>B" G\1QJPMGJ$ /6EB" &?;;8>B" G\1QJPMGJ$

# % # % ,@7D"<>"K6BF;@@9" # % # %,@7D"<>"=8776;X"=;6O7"EA6=8X"@;"K6E898>B"

# % # % .69A"=8776;" # % # % ,@7DLX"9?EBL"E=F@@7VD6L=6;8"# % # % /8EB"8JB8;9<>6B<@>"j"(>E<D8" # % # % '@K6==@"E9@G8"# % # % /8EB"8JB8;9<>6B<@>"j")?BE<D8" # % # % 1877"O6B8;"# % # % #@;=8D"F@B"6<;"F86B" # " # " &6;A8B"<>"K8D;@@9"# % # % S6D"O6B8;"<>"K6E898>B" # " # " &6;A8B"<>"9@EB"A6;BE"@:"BF8"F@?E8"# % # % ,@7D"C<E<K78"@>"8JB8;<@;"@:"F@?E8" # " # " #86BF8;"@;"D@O>"K8DD<>M"

# % # %S86C<7L"O@@D8D"@;"D69A"E?;;@?>D<>ME" " " "

"3),-"'S(%53"*\)$'"T)$0"/*0-%'3$1F8>"O8;8"L@?;"A6;8>BE"96;;<8DW"QQQQQQQQQQQQQQQQQQQQQQQQQQQ"(:"E8A6;6B8DX"OF8>W" QQQQQQQQQQQQQQQQQ"(:"D<C@;=8DX"OF8>W"QQQQQQQQQQQQQQQQQQQQQQQQQQ"(:";896;;<8DX"OF8>W""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"&?EB@DL"6;;6>M898>BEI"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"",)'S-0"j"/-03)%*+"*M8"6B"L@?;"K<;BF""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-BF><=<BL"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-D?=6B<@>"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"\7@@D"BLA8"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

#*'S-0"j"/-03)%*+"*M8"6B"L@?;"K<;BF""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-D?=6B<@>""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-BF><=<BL""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"\7@@D"BLA8"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ

![""

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n8;GE"D?;<>M"E788A"# %<MFB96;8E"# 3788AE"9@;8"BF6>">@;967""

1BYJKE9N$# +@@GE"E<=G"# 576H8D"7@@G"# )C8;O8<MFB"# $>D8;O8<MFB"# /?A<7E"?E?677L"76;M8"# $>?E?677L"7@>M"8L876EF8E"# /?A<7E"?>?E?677L"E9677"# .6;G"=<;=78E"?>D8;"8L8E"# 08D"7<AE"# 08D":<>M8;E"# 08D"B@8E"# 18KK8D"B@8E"# 08D"86;E"# .@?K78"a@<>B8D"# +L9AF">@D8E"8>76;M8D"<>">8=G"# S86D"O6;9E"# S86D"EO86BE"# %<MFB"EO86BE"# *K>@;967":6B<M?8"# #6<7?;8"B@"BF;<C8"# &@7D"677"@C8;"# &@7D"F6>DE"6>D":88B"# &@7D"<>B@78;6>=8"# S6>DEV":88B"j"C8;L"EO86BL"# /8;EA<;6B<@>"j"@DD"@D@;"$JTK.$# /678>8EEX"E8C8;8"# #?>M?EV":<>M8;>6<7E"# #?>M?EV"B@8>6<7E"# .6>D;?::"# &F<=G8>"EG<>"# )<7L"EG<>"# /6B=FL"D?77>8EE"# 38K@;;F86"@>":6=8"# 'F<=G"=677?E8E"# *BF78B8E":@@B"# #88B"j"EB<>GL"# .<6A8;";6EF"# )DD"K@DL"@D@;"

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

!`""

3T,/'),"0-^(-1"N&)%'(%$-.P$

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

4K:GJLKXG]$E";57;>'3$# #6;B<>M"j";8M?76;$# #6;B<>M"j"EB<>GL$# *>67":<EE?;8E$# 08D";<>M"6;@?>D"6>?E$# 3B@@7E"K?7GL$# 3B@@7E"7<MFB"=@7@;$# 3B@@7E"C8;L"EB<>GL$# 3B@@7E"O<BF"K7@@D$# 3B@@7E"O<BF"9?=@?E$# 3B@@7E"O<BF"?>D<M8EB8D":@@D$# #76B?78>=8$# 3B@@7"@D@;":@?7$# 3B@@7"@D@;"L86EBL$# 3B@@7E"A678$# 3B@@7E"E7<9L$# 3B@@7E"O6B8;L$$G9LK.:$# /@@;"6AA8B<B8"# 'F<;EB"# -JB;898"O6B8;"D;<>G<>M"# \<>M8<>M"# \;86D"=;6C<>M"# &;6C<>M":@;"=6;K@FLD;6B8E"# &;6C<>M":@;"a?<=8"# &;6C<>M":@;"E67B"# .<8B"E@D6"=;6C<>M"# /<=6"N86B<>M">@>_8D<K78EP"# *K>@;967":@@D"=;6C<>ME"# &6;K@FLD;6B8"<>B@78;6>=8"# 3B6;=FV"D<E6==F6;<D8"

<>B@78;6>=8"# 3?M6;"<>B@78;6>=8"# 367<=L76B8"<>B@78;6>=8"# )J676B8"<>B@78;6>=8"# /F8>@7<=E"<>B@78;6>=8"# ,35"<>B@78;6>=8"# #@@D"=@7@;<>M"<>B@78;6>=8"# 57?B8>"<>B@78;6>=8"# &6E8<>"<>B@78;6>=8"

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a8=BE"F87A"# &?;<@?EV"M8BE"<>B@"BF<>ME"# -;;6B<="# $>6K78"B@"A;8D<=B"6=B<@>E"# .8EB;?=B<C8"# SLA8;6=B<C8"# &@>EB6>B"9@C898>B"# ,87BE"D@O>"# '6>B;?9E"# 387:"9?B<76B<@>"# 0?>E"6O6L"# n?9AE"OF8>"A786E8D"# 1F<;7E"E87:"7<G8"6"B@A"# &7<9KE"B@"F<MF"A76=8E"# (>E<EBE"@>"OF6B"O6>B8D"# ';<8E"B@"=@>B;@7"@BF8;E"# S86D"K6>M<>M"

!d""

3T,/'),"0-^(-1"N&)%'(%$-.P$

3=5D75%:A5:O%D==%:C6659>%7F;<>8;7%8::C66?9@%86%<65759>%?9%>A5%<D7>%X%;89>A7E%"6GB9XKQM]$E";57;>'3$# #677EX"M8BE"F?;B";?>><>M"

=7<9K<>M"# .@8E"@AA@E<B8"@:"6EG8D"# 3<77L"# 3F;<8GE"# S@7DE"F6>DE"<>"EB;6>M8"A@E8"# 3A8>DE"B<98"O<BF"A@<>B78EE"

B6EG"# 3B6;8E"6B"@O>"F6>DE"# '@8"O67G<>M"# *;=F8D"K6=G"O<BF"K;<MFB"7<MFBE"# (9<B6B8E"@BF8;E"# #<>M8;":7<=G<>M"# #76AE"F6>DE"# +<=G<>M"# +<G8E"EA<>><>M"@Ka8=BE"# +<G8E"B@":7<=G":<>M8;"<>"8L8"# +<G8E"B@"EA<>"BF<>ME"# 0FLBF9<=";@=G<>M"# 376AA<>M"K@@GE"# '@@BF"B6AA<>M"# ^<E?67"EB<9E"# 1<MM78":<>M8;":;@>B"@:":6=8"# 1<MM78":<>D8;"E<D8"@:":6=8"# \<B8E"@;"=F8OE":<>M8;E"# \<B8E"O;<EB"@;"K6=G"@:"F6>DE"# &F8OE"@>"BF<>ME""?QQ4$# *A6BFL"# \76>G"7@@G"# .8A;8EE<@>"# .8B6=F8D"# .<E<>B8;8EB"# -L8"=@>B6=B"A@@;"# (E@76B8E"# %8M6B<C8":;<MFB"O<BF@?B"=6?E8"# *7O6LE":;<MFB8>8D"# *>M?<EF"# .<E=@>>8=B8D"

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a?=B<C<B<E"# -L8"=;?EB<>M"# -L8"A;@K789"# +<D"96;M<>";8D>8EE"# -J69<>8E"KL"E<MFB"# #6<7E"B@"K7<>G"6B"K;<MFB"7<MFB"# +<G8E":6>E"# +<G8E":7<=G8;<>M"7<MFBE"# +@@GE"@?B"@:"BF8"=@;>8;"@:"8L8"# /@@;"C<E<@>"# /?BE"8L8"B@"K;<MFB"7<MFB"@;"E?>"

JG.JQMY]$E";57;>'3$# 3B;6K<E9?E"N=;@EE8D"8L8P"# #86;:?7"@:"F6;978EE"@Ka8=B"# #86;:?7"@:"?>?E?67"8C8>BE"# $>6O6;8"@:"D6>M8;"# $>6O6;8"@:"A8@A78EZ":887<>ME"# $>6O6;8"@:"E87:"6E"A8;E@>"# $AE8B"<:"BF<>ME"=F6>M8"# $AE8B"<:"BF<>ME"6;8>ZB";<MFB"# *D@ABE"=@9A7<=6B8D";<B?67E"# &6;X"B;?=GX"B;6<>"@KE8EE<@>"# &@778=BE"A6;B<=?76;"BF<>ME"# .;6OE"@>7L"=8;B6<>"BF<>ME"# #<J6B8D"@>"@>8"B@A<="# +<>8E"@Ka8=BE"A;8=<E87L"# 08A86BE"@7D"AF;6E8E"# 08A8B<B<C8"A76LV"@Ka8=BE"# #<>M8;"B<A"E]?88H<>M"# S6B8E"O86;<>M"EF@8E"# (>E8>E<B<C8"B@"A6<>"# +<G8E"F86D"K?;;@O8D"# +<G8E"F86D"A;8EE8D"F6;D"# +<G8E"F86D";?KK8D"# +<G8E"F86D"?>D8;"K76>G8B"# +<G8E"B@"K8"F87A"?AE<D8"D@O>"# +<G8E"B@"K8"EO?>M"<>"BF8"6<;"# ^8;L"<>E8>E<B<C8"B@"A6<>"# ^8;L"E8>E<B<C8"B@"A6<>"$.GPMQ?PJEPN9M$# &7?9E<>8EE$# &@@;D<>6B<@>"$# #<>8"9@B@;"A@@;"# 5;@EE"9@B@;"A@@;"# S@7DE"K<H6;;8"A@EB?;8"# SLA8;6=B<C<BL"# /FLE<=677L"6OGO6;D"# 0@=G<>M"# 3B<::8>E"K@DL"OF8>"F87D"# &67:"=;69AE"# #@@B"=;69AE"

!h""

3T,/'),"0-^(-1"N&)%'(%$-.P$

3=5D75%:A5:O%D==%:C6659>%7F;<>8;7%8::C66?9@%86%<65759>%?9%>A5%<D7>%X%;89>A7E%".GPMQ?PJEPN9M]$E";57;>'3$# ,?E=78"A6<>"# ,?E=78"B@>8"B8>E8"# ,?E=78"BO<B=F8E"# #<EB"=78>=F<>M"# n6O"=78>=F<>M"# /@@;"9?E=78"B@>8V"7<9A"# '<=E"# ,?E=78"B@>8"7@O"B;?>G"# ,?E=78"O86G>8EEX"6B;@AFL"# ,?E=78"B@>8"7@O"677"@C8;"# ';89@;E"# &@M><B<C8"D876LE"# ,89@;L"A@@;"# /@@;"6BB8>B<@>X":@=?E"# 37@O"6>D"E7?MM<EF"# -JA;8EE<C8"76>M?6M8"D876L"$J1GGEB$# %8C8;"EA@G8$# )==6E<@>67"O@;DE"OF8>"

8J=<B8D$# -JA;8EE<C8"76>M?6M8"A@@;$# %@"6>EO8;E"E<9A78"]?8EB<@>E$# /@<>BE"B@"@Ka8=BEV"=6>ZB">698$# 3A88=F"6A;6J<6$# .@8E">@B"6EG"]?8EB<@>E$# \6KK7<>M$# *EGE"?E<>M"oL@?p">@B"o(p$# *>EO8;E"KL";8A86B<>M"]?8EB<@>$# 08=8AB<C8"76>M?6M8"A@@;$# 36LE"o(p$# 36LE"o>@p$# 36LE"oL8Ep$# +@EB"76>M?6M8"6B"!4_4U"9@>BFE$# +@EB"76>M?6M8"6:B8;"4U"9@>BFE$# 3=;<AB<>M$# 3B?BB8;<>M$# '67GE"B@"E87:$# /@@;"6?D<B@;L"A;@=8EE<>M$

$J1GGEB]$E";57;>'3$# $>?E?67"E@?>D"@:"=;L$# $E8E"@>8"O@;D":@;"6>@BF8;$# 0<M<D"K8F6C<@;E$# /@@;"=@>:<D8>=8$# '<9<D$# &@;;8=BE"<9A8;:8=B<@>E$$MGJ1KM9LQMY$# />8?9@><6$# \6D"@D@;"<>">@E8$# \;86BF"F@7D<>M$# \;@>=F<B<E$# &@>M8EB<@>"=F6>M8"O<BF"

E86E@>$# &@>M8EB<@>"<>"BF8":677$# &@>M8EB<@>"<>"BF8"EA;<>M$# &@>M8EB<@>"<>"BF8"E?998;$# &@>M8EB<@>"<>"BF8"O<>B8;$# &@?MF$# /@EB">6E67"D;<A$# 0?>>L">@E8$# 3<MF<>M$# 3<>?E":?77>8EE$# 1F88H<>M$# T6O><>M$$MG1MQ4PELKXG$# 5<;7EI"-6;7L":<;EB"A8;<@D$# \@LEI"+6;M8"B8EB<=78E$# -6;7L"K;86EB"D8C87@A98>B$# -6;7L"A?K<="F6<;$# 5<;7EI"^6M<>67"@D@;$$PMK.9MY$# #;8]?8>B"?;<>6B<@>$# \8D"O8BB<>M"6:B8;"6M8"U$# )DD"?;<>6;L"@D@;$# $;<>6;L"F8E<B6>=L$# $;<>6;L"B;6=B"<>:8=B<@>E$

$PMK.9MY]$E";57;>'3$# $;<>6;L"?;M8>=L$# .;L"6B"><MFB$# 38<H?;8E"j":@=67$# 38<H?;8E"j"M8>8;67<H8D$# 38<H?;8E"j"M;6>D"967$# 38<H?;8E"j"A8B<B"967$# $E?67":6EB"F86;B"K86B$# S86;B"9?;9?;$# S86D6=F8E$# n@<>B"A6<>E$# +8M"A6<>E$# ,?E=78"A6<>E$

""""""""""""""""""""""""""$

!k""

0-*.(%-33"*33-33,-%'$(D>5%89%D%7:D=5%8M%Y%SQ56F%R?==?9@V%>8%T%S98>%R?==?9@V%(>"@;D8;"B@"<9A;@C8"L@?;"=F<7DZE"F867BFX"F@O"O<77<>M"6;8"L@?"B@I"

(D>5%89%D%7:D=5%8M%Y%SQ56F%R?==?9@V%>8%T%S98>%R?==?9@V"" 3<M><:<=6>B7L"9@D<:L"L@?;"D<8B" eeYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"" '6G8"E8C8;67">?B;<B<@>67"E?AA7898>BE"86=F"D6L" eeYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"" 288A"6";8=@;D"@:"8C8;LBF<>M"L@?"86B"86=F"D6L" eYYYYYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"" ,@D<:L"L@?;"7<:8EBL78"N8YMYX"O@;G"D896>DEX"E788A"F6K<BEP""eeY" ! [" ! U" ! R" ! 4" ! !"" /;6=B<=8"6";876J6B<@>"B8=F><]?8"eeYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"" ->M6M8"<>";8M?76;"8J8;=<E8" eeYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"" S6C8"A8;<@D<="76K"B8EBE"B@"6EE8EE"L@?;"A;@M;8EE" eeYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !""&@998>BEI ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ "T@?;"6K<7<BL"B@"@;M6><H8"6>D":@77@O"BF;@?MF"@>"BF8"6K@C8"F867BF";876B8D"6=B<C<B<8EI""eeeeeeeeeeeeYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"

(D>5%89%D%7:D=5%8M%Y%SQ56F%:89M?H59>V%>8%T%S98>%:89M?H59>V%(:" L@?" 6;8" >@B" =@>:<D8>B" @:" L@?;" 6K<7<BLX" OF6B" 6EA8=BE" @:" L@?;E87:" @;" L@?;" 7<:8" 786D" L@?" B@" ]?8EB<@>" L@?;"=6A6=<BL"B@":?77L"8>M6M8"<>"BF8"6K@C8"6=B<C<B<8EW"____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ "*B"BF8"A;8E8>B"B<98X"F@O"E?AA@;B<C8"D@"L@?"BF<>G"BF8"A8@A78"<>"L@?;"F@?E8F@7D"O<77"K8"B@"L@?;"<9A7898>B<>M"BF8"6K@C8"=F6>M8EW" eeeeeeeeeeeYYeeeeeeeYYYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"

(D>5%89%D%7:D=5%8M%Y%SQ56F%7C<<86>?Q5V%>8%T%SQ56F%C97C<<86>?Q5V%&@998>BEI ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ "S@O"9?=F"@>_M@<>M"E?AA@;B"6>D"=@>B6=B"N8YMYX"B878AF@>8"=@>E?7BEX"8_96<7"=@;;8EA@>D8>=8P":;@9"@?;"A;@:8EE<@>67"EB6::"O@?7D"K8"F87A:?7"B@"L@?"6E"L@?"<9A7898>B"L@?;"=F<7DZE"F867BF"A;@M;69W""eeeeeeeYYYYYYYYYYYYYYY" ! [" ! U" ! R" ! 4" ! !"

(D>5%89%D%7:D=5%8M%Y%SQ56F%M65BC59>%:89>D:>V%>8%T%SQ56F%?9M65BC59>%:89>D:>V%&@998>BEI ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ "

4g""

,*49Y$4KGL$4K9MY$K.JLMPELKQ.J""/+-*3-"3$\,('"1('S"'S-"-%'(0-"(%'*2-"#)0,Y"".)"%)'"1*('"*%."\0(%5"1('S"T)$"')"'S-"*//)(%',-%'Y""1-"%--."')"0-^(-1"/0()0"')"T)$0"*//)(%',-%'Y""(B"<E"<9A@;B6>B"B@"G88A"6>"6==?;6B8";8=@;D"@:"L@?;"?E?67":@@D"6>D"K8C8;6M8"<>B6G8"6E"6"A6;B"@:"L@?;"B;86B98>B"A76>Y""/786E8"=@9A78B8"BF<E".<8B".<6;L":@;"R"=@>E8=?B<C8"D6LE"<>=7?D<>M"@>8"O88G8>D"D6LY"

• .@">@B"=F6>M8"L@?;"86B<>M"K8F6C<@;"6B"BF<E"B<98X"6E"BF8"A?;A@E8"@:"BF<E":@@D";8=@;D"<E"B@"6>67LH8"L@?;"A;8E8>B"86B<>M"F6K<BEY"

• 08=@;D"<>:@;96B<@>"6E"E@@>"6E"A@EE<K78"6:B8;"BF8":@@D"F6E"K88>"=@>E?98D"• .8E=;<K8"BF8":@@D"@;"K8C8;6M8"6E"6==?;6B87L"6E"A@EE<K78"8YMYX"9<7G"_"OF6B"G<>DW"NOF@78X"4mX">@>:6BPq""

B@6EB"NOF@78"OF86BX"OF<B8X"K?BB8;8DPq"=F<=G8>"N:;<8DX"K6G8DX"K;86D8DPq"=@::88"ND8=6::8<>6B8D"O<BF"E?M6;"6>D"r"b"rPY"

• 08=@;D"BF8"69@?>B"@:"86=F":@@D"@;"K8C8;6M8"=@>E?98D"?E<>M"EB6>D6;D"986E?;898>BE"E?=F"6E"h"@?>=8EX"r"=?AX"!"B86EA@@>X"8B=Y"

• (>=7?D8"6>L"6DD8D"<B89EY""#@;"8J69A78I""B86"O<BF"!"B86EA@@>"F@>8LX"A@B6B@"O<BF"4"B86EA@@>E"K?BB8;X"8B=Y"

• 08=@;D"677"K8C8;6M8EX"<>=7?D<>M"O6B8;X"=@::88X"B86X"EA@;BE"D;<>GEX"E@D6EVD<8B"E@D6EX"8B=Y"• (>=7?D8"6>L"6DD<B<@>67"=@998>BE"6K@?B"L@?;"86B<>M"F6K<BE"@>"BF<E":@;9"N8JY"=;6C<>M"EO88BX"EG<AA8D"

9867"6>D"OFLX"OF8>"BF8"9867"O6E"6B"6";8EB6?;6>BX"8B=PY"• /786E8">@B8"677"K@O87"9@C898>BE"6>D"BF8<;"=@>E<EB8>=L"N;8M?76;X"7@@E8X":<;9X"8B=YP"

$(,%"#(,!+)%%"%698I""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" .6B8I""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"".*T"!"

LK?G" !QQ4I6GXGM9:GI9?QP.L$ EQ??G.LJ$$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $

"\@O87",@C898>BE"NsX":@;9X"=@7@;PI"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"3B;8EEV,@@DV-9@B<@>EI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ")BF8;"&@998>BEI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"

4!""

".*T"4"

LK?G" !QQ4I6GXGM9:GI9?QP.L$ EQ??G.LJ$

$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $

""\@O87",@C898>BE"NsX":@;9X"=@7@;PI"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"3B;8EEV,@@DV-9@B<@>EI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ")BF8;"&@998>BEI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"".*T"R"

LK?G" !QQ4I6GXGM9:GI9?QP.L$ EQ??G.LJ$$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $$ $ $

"\@O87",@C898>BE"NsX":@;9X"=@7@;PI"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"3B;8EEV,@@DV-9@B<@>EI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ")BF8;"&@998>BEI""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""

44""

?JO$*$?G4KE9N$JY?1LQ?ILQ\KEKLY$OPGJLKQ..9KMG$$$.9?G0""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""49LG0"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""'F8"'@J<=<BL"6>D"3L9AB@9"3=;88><>M"t?8EB<@>>6<;8"<D8>B<:<8E"EL9AB@9E"BF6B"F87A"B@"<D8>B<:L"BF8"?>D8;7L<>M"=6?E8E"@:"<77>8EEX"6>D"F87AE"L@?"B;6=G"L@?;"A;@M;8EE"@C8;"B<98Y"06B8"86=F"@:"BF8":@77@O<>M"EL9AB@9E"K6E8D"?A@>"L@?;"F867BF"A;@:<78":@;"BF8"A6EB"Rg"D6LEY"(:"L@?"6;8"=@9A78B<>M"BF<E"6:B8;"L@?;":<;EB"B<98X"BF8>";8=@;D"L@?;"EL9AB@9E":@;"'41+"BF8"76EB"Uh"F@?;EY"1QK.L$JE9NG""g"u"%8C8;"@;"679@EB">8C8;"F6C8"BF8"EL9AB@9""!"u")==6E<@>677L"F6C8"<BX"8::8=B"<E">@B"E8C8;8""4"u")==6E<@>677L"F6C8X"8::8=B"<E"E8C8;8""

R"u"#;8]?8>B7L"F6C8"<BX"8::8=B"<E">@B"E8C8;8""U"u"#;8]?8>B7L"F6C8"<BX"8::8=B"<E"E8C8;8"

TGY$LQ$OPGJLKQ..9KMG""*DD"<>D<C<D?67"E=@;8E"6>D"B@B67"86=F"M;@?AY"*DD"86=F"M;@?A"E=@;8"6>D"M<C8"6"M;6>D"B@B67Y""v")AB<967"<E"78EE"BF6>"!g""v",<7D"'@J<=<BLI"!g_[g""v",@D8;6B8"'@J<=<BLI"[g_!gg""v"38C8;8"'@J<=<BLI"@C8;"!gg"______________________________________________________________________________________________________________________________".(5-3'(^-"'0*&'""QQQQQ"%6?E86"@;"C@9<B<>M"QQQQQ".<6;;F86""QQQQQ"&@>EB<A6B<@>""QQQQQ"\7@6B8D":887<>M""QQQQQ"\87=F<>M"@;"A6EE<>M"M6E""QQQQQ"S86;BK?;>""QQQQQ"(>B8EB<>67V3B@96=F"A6<>""% % !8>D="QQQQQQQ"""-*03""QQQQQ"(B=FL"86;E""QQQQQ"-6;6=F8EX"86;"<>:8=B<@>E""QQQQQ".;6<>6M8":;@9"86;""QQQQQ"0<>M<>M"<>"86;EX"F86;<>M"7@EE""% % !8>D="QQQQQQQ"""-,)'()%3""QQQQQ",@@D"EO<>ME""QQQQQ"*>J<8BLX":86;"@;">8;C@?E>8EE""QQQQQ"*>M8;X"<;;<B6K<7<BL"@;"6MM;8EE<C8>8EE""QQQQQ".8A;8EE<@>""% % !8>D="QQQQQQQ"""-%-05TV*&'(^('T""QQQQQ"#6B<M?8X"E7?MM<EF>8EE""QQQQQ"*A6BFLX"78BF6;ML""QQQQQ"SLA8;6=B<C<BL""QQQQQ"08EB78EE>8EE""% % !8>D="QQQQQQQ"""-T-3""QQQQQ"16B8;L"@;"<B=FL"8L8E""QQQQQ"3O@778>X";8DD8>8D"@;"EB<=GL"8L87<DE""QQQQQ"\6ME"@;"D6;G"=<;=78E"?>D8;"8L8E""QQQQQ"\7?;;8D"@;"B?>>87"C<E<@>"ND@8E">@B"""""""""""

<>=7?D8">86;"@;":6;_E<MFB8D>8EEP""% % !8>D="QQQQQQQ"

S-*.""QQQQQ"S86D6=F8E""QQQQQ"#6<>B>8EE""QQQQQ".<HH<>8EE""QQQQQ"(>E@9><6""% % !8>D="QQQQQQQ"""S-*0'""QQQQQ"(;;8M?76;"@;"EG<AA8D"F86;BK86B""QQQQQ"06A<D"@;"A@?>D<>M"F86;BK86B""QQQQQ"&F8EB"A6<>""% % !8>D="QQQQQQQ"""n)(%'3V,$3&+-3""QQQQQ"/6<>"@;"6=F8E"<>"a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

,)$'SV'S0)*'""QQQQQ"&F;@><="=@?MF<>M""QQQQQ"56MM<>MX":;8]?8>B">88D"B@"=786;"

BF;@6B""QQQQQ"3@;8"BF;@6BX"F@6;E8>8EEX"7@EE"@:"

C@<=8""QQQQQ"3O@778>VD<E=@7@;8D"B@>M?8X"M?9X"

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

4R""

J19EG$!QM$944KLKQ.9N$.QLGJ$___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________