124

NO.,
AGE,

WEIGHT
POUNDS
HEICHT

PAST

SEX

HISTORY

INJURIES

CENTIMETERS

BLOOD PRESSURE
HEART

&

LUNGS

ABDOMEN
EENT

Gu or Gyn

SKIN

1055
1f

1056

8-3/4#

1M

LOST

15¢

No m

8-1/2 #|

Nom

nostrils; no hx.
of sig. '64

30-1/4
96.1

78/58
Gr I apical sys
m

Polio (7) date?;
no sig. history
aside fran leg
pains '6h

25-1/4
85.2

Gr I apical sys
tm

1F

1058
1M

1503

6M

1504
2M

I00 6¢ 0

Sores on

Scars

Select target paragraph3