oe een ee Standard Form #8 Retised April 1964 ' General Services Administration Intceragenvy Comm on Mednal Records 1, LAST NAME—FIRST NAME—MIDOLE NAME ™~ 4. HOME ADORESS (Number, atreet or RFD, city hy Lp7 ee 5 . . Aas lett ~ Le x / ty 4) ~ ey ~ CY iy | -_—s ~- . CLINICAL EVALUATION (Check each femin appropriate column, enter '' 2 tact evaluated } . HEAO, FACE 19 NOSE NECK ae ; 1. at! ‘ : ty TT ce wpe} ot ' van oo TIME IN THIS CAPACITY (Total) NOTES ABHOR. ) } a ‘ely ¢ 11. ORGAMIZATION UNIT bal 4 ,/ t ply / z1 Jat re oa hed P fi ne he ee 17, aatiné Oa Medbarson,GA 50330 18. fos A . J il ‘ ‘ y oe de ryon 16. OTHER INFORMATION US Army Herith Clinic ra 7 a 14. NAME, RELATIONSHIP, AND ADORESS OF NEXT OF (IN ! . 15, EXAMS) BlOGlontexlinkh WdoLOmeRCtLOn MOR: \ 710. AGENCY cpp | 4ebi (3 Al te ety} Bou stee Cle mee. Ce) Fe rn % ~ } ; 6. DATE OF EXAMINATION Og §. TOTAL YEARS GOVERNMENT SERVICE MILITARY CIVILIAN , pot ‘ _. 3. IDENTIFICATION NO. ig $ PURPOSE’ OF EXAMINATION Sod 13, PLACE OF BIRTH , / - . 8. RACE V7 ; 12, DATE OF BIATH ~ town, Stafe and ZIP Code) Learns - ' pe f. t 3. Fite 88-117 | 2. GRADE AND COMPONENT OR POSITION ? ~ yyw HOAED 4 REPORT OF MEDICAL EXAMINATION FPMR !01-11 dov-s fGt ‘= (Descr:be ever comme ne | abnormality in detatl LAST SIX MONTHS | Enter pertinent item number before each ontinue in rtem 7J and use addtional sheets if necessary ) MAL AMD SCALP 20 SINUSES a 21. MOUTH AND THROAT , “ 22) 'y _ CARS (ime tert canals’ (Audiiory GENERAL acuity wader lems 70 and 273 23. DAUMS (Perforation) —K 4 . _ (Wermel acuip and refraction 24 EVES ~GEMERAL wader tfeme 7? 60 and G7) 25 OPHTHAL MOSCOPIC 26. PUPILS (Aiguality and reaction) 27 &L f (4aseginied poradiel OCULAR MOTILITY ments npstegm ne! mace 28 LUNGS AMO CHEST (include breasts) . 29. HEART (Taras, #ire,rAgttm, sounds) ¥ 30. VASCULAR SYSTEM (\ericosities. ete ) PRIVACY ACT MATERIAL REMOVED 31. ABOOMEN AND VISCERA (/nelide Aermia} ban 1 32 # (Hemorrderds 4stular) ANUS AND RECTUM (Prestate of indicated) 23) ENCOCRINE SYSTEM / 44. G-U SYSTEM , 3S. UPPER EXTREMITIES metien) UNTenetA renee of M. FEET (CBrer pt feet y 37. LOWER EXTREMITIES |een A range of motion) ye SPINE. OTHER MUSCULOSKELETAL | 39 IDENTIFYING BODY MARKS SCARS. TATTOOS f v1 40. SKIN, LYMPHATICS oo Af, Pr. QZ. PSYCHIATRIC (Speetspany prreenativ dertatian! tL 4and \ + [-“d) . ~ MEUROLOGIC (Kemiiorium frete wader item 72) 43. PELVIC /AK Fe maics onip) (Check how done) ‘ OCvacina, CJ recrar (Continuesn item 7)) REMARKS AND ADDITIONAL DENTAL DEFECTS ANO DISEASES 44, DENTAL (Place appropriate symbols, shown in examples, above or below mumber of upper and lower teeth.) ‘ Sheran ara-z Resteruble tr 0 zm 2 on 45, URINALYSIS: B. ALBUMIN Cc. SUGAR 3 » ' «4 D> Nate 5 6 8 A SPECIFIC GRAVITY 27 /. —_2- “f Tey 47. SEROLOGY (Specify test weed And reeull) BPH ROW REACTYIVr . 7 B&B Jud“) J I é 1 8] BB | 9 2 190 3 mH z Misseny teeth ~ 6 SI ein I 2 ' t2 ra) dentures 9 } mw 19 = ‘| | Paved Purtiat x deatures ee L 1 6 & 18 17 , i . fi Ve, 5 . — ™.. tF LABORATORY FINDINGS AG. CHEST X RAY (Place, dole, log nubider Ent pantry SS f3 KEGAT] 7 Uated2gray 79 US Aray Health Clinic BD MICROSCOPIC 46. EXG k Repliced Ay 49, BLOOD TYPE AND AH FACTOR 30, OTHER TESTS Ft McEherson, GA 30330 . Het 47 O OO