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 {