Revised Apel (208
General services Adininsistration
Intcragene, Comm. on Medial Records
.
FEMA Lote LE yuge3
1. LAST NAME-FIRST MAME--MIOGLE NAME
—_
oo.
RT
.
~
_
OF
.
PAEDICAL
a
.
_
‘
4
AY\
I
“4Y
12. DATE OF BIRTH
| 10. AGENCY
13, PLACE OF BIRTH
_.
|
\S
ia
Nf ,
.
15. EXAMINING FACILITY OR EXAMINER
1
TA
AD
-
Il
Co
Ss
LO L we UC, ene Aaa
____Fort- LeavenworthKansas 66027
17, RATING ORSPECIALTY
urn, enter “'NE' ft not evaluated )
|
19
NOSE
|
20. SINUSES
NECK
EARS—
_
i
_
|
f
4p
moee-
LUNGS ANO CHEST (faclude breasts)
a
. WASCULAR SYSTEM ( Vartcosifies, efc.)
else
4—4—
, ABCOMEN AND VISCERA (Jnelude hernia)
ANUS AND RECTUM
{demorrAods, Aatular)
(frostate. if indicated)
ENCOCRINE SYSTEM
. G-U SYSTEM
>
LAST SIX MONTHS
=
(Aapoginted
parafiel
OCULAR MOTILITY Ot
nestagmuel
Kj
——$——_
!
(Wiaual acuity aad refraction
~GENERAL wader stema 39, 60 and U7)
L
OPHTHAL MOSCOPIC
to
i
se
|
(Perforation )
(Perf
. HEART (Thrust, size, rythm, sounds)
—4 — —
.
MAL
. PUPILS (Fquality and reaction)
“
c)
tint @& eat canals! (Auditory
GENERAL a@cuity under items TO and mel
. DRUMS
_ EYES
_.
(Describe ever abnormality in detail.
Enter pertinent item number before each
comment.
ontinue in :tem 73 and use additional sheets if necessary.)
se . jd ft. pff
_
9 JAN 1075
AMO SCALP
. MOUTH AMO THROAT
bp a pe a Fe pe
Be
Pe
net mw
Phe
we
my
re
A ie
~~
no
a)
o
_
-4
HEAD, FACE
he
18
a
TIME IN THIS CAPACITY (Total)
CLINICAL EVALVATION
{ NOTES.
Teck cach tem in appropriate col “GROR
Mal
_
16, OTHER INFORMATION
Ue MONSON ABSA? HOSPITAL
<St
6. DATE OF EXAMINATION
14. NAME, RELATIONSHIP, AND ADDRESS OF NEXT OF KIN
|
AND
te
{1. ORGANIZATION al
j
CJ S. ()
yt?
*
8-117
3, IOENTIFICATION NO,
3. PURPOSE OF EXAMINATION
TS
CIES
ACGis
ay
—_
19. TOTAL YEARS GOVERNMENT SERVICE
[MILITARY —
| CIVILIAN
[hy soo
at
oye gg
'
{ 2. GRAGE AND COMPONENT OR POSITION
4 HOME ALORESS (Number, street or AFD, city or town, Staleand Z1P Code)
Poe UD
7. SEX
| 8, RACE
:
EXAMINATIC
~ PRIVACY ACT MATERIAL REMOVED
uw
. UPPER EXTREMITIES iSivenath. rener of
|
| 36. reer
threepi feeti
| 37. LOWER EXTREMITIES (siremoth.
ranpe of motion)
| 38. SPINE, OTHER MUSCULOSKE:ETAL
wa
3
IDENTIFYING BOOY MARKS SCARS, TATTOOS
a O. SKIN, LYMPHATICS
4 « MEYROLOGIC (Bguifibrium [este ander item 22)
a 2, PSYCHIATRIC (Speesfyany pereenality deriution!
43, PELVIC (Femates only) (Check how done)
{
Ovacinat Corectar
(Continue in item 73)
ia. DENTAL (Place appropriate
.
—
" or belaw number of upper and tow er teeth, 4b, )
REMARe..
<9 Oeste
AODITIONAL DENTAL
tymbols, shown
in examples, above
Cereens a
hi}
f
;
Revioruble
:
a
R
H
T
32
|
teeth
i
é
;
4
Non-
‘
]
ordh
elie .
é
,
:
agi:
1
:
teeth
a
8
f
j
oI
\
(4a)
Replaced
by
dentures
.
|
(
f
1
.
Fixed
}
:
Partial
) dentures
;
SO:
oo
3
30
>
2
27
«4
2B
24
3B
.
;
45. URINALYSIS: A. SPECIFIC GRAVITY / } a
p. aLsuUMINN@Zatives
€ SUGAR Nooativa
47, SEROLOGY (Specify teat used and result)
Epp y
= if On
1
Missiny
React ive
2
2
Ab WEL
48. EKG
*.
19
1
8617:
4
*F
3
T
j
:
LABORATORY FINDINGS
46. CHEST X-RAY (Plage, date, film number and esis!
D. MICROSCOPIC
r)
2
L
‘
49, BLOOD TYPE AND RM
FACTOR
Ke KHOALAUMAL
Cprat
“
4
Uy, BR MUNSON APMY HOSPITAL
;
Fort Eeevenir::". Kuneas 66027
vat
vd
.
50, OTHER TESTS
.
4
7
-
5
{