PRIVACYACT MATERIAL REMOVED 405488 DATE MEDICAL CONDITION - PHYSICAL PROFILE RECORD 18 Oct 1978 For use of this form, see AR 40-501; the proponent agency is The Surgeon General's Office FROM: (Include Zip Code) TO: (Include Zip Code) Cdr HQ Joint Task Group Med Ofcr, Wd B18 Field Command Defense Nuclear Agency FNEWETAKATQLL MARSHALL ISLAND Tripler Army Medical Center Tripler AMC, HI 96859 LASTN AM E “FIRST NAME - MIDDLE INITIAL, GRADE, SOCIAL SECURITY ACCOUNT NUMBER AND ORGANIZATION INSTRUCTIONS Complete Section D of this form in lieuof DA Form 8—118, whenever a medical board is held for the sole purpose of permanent revising physical profile to or from a numerical designator “3”. PREPARE COPIES AS INDICATED BELOW: Unit Commander/ Personne! Officer — 1 copy when Item 1 or 2 is checked. Appropriate Commander or HQ - 1 copy when Item 3 is b. Orgn: same as above. checked. Health Record Jacket (DD Form 722)- 1 copy. Clinical Record - 1 copy when appropriate. 3| X — + —} __] w SECTION A- DUTY STATUS (Check Applicabie Item(s)} INDIVIDUAL IS RETURNED TO YOUR UNIT FOR OUTY (AR 40—3, AR 635 — 40} INDIVIDUAL IS RETURNED TO YOUR UNIT FOR SEPARATION PROCESSING (AR 40—3, AR 635—40} INDIVIDUAL is (IS) RYN= UALIFIED FOR MevicaLty quar AS EVIDENCED 8Y A MEDICAL EXAMINATION AND & REVIEW OF HIS HEALTH RECORO THIS OATE—_____16_flep SECTION B- PHYSICAL PROFILE (Complete all items, When applicable "R" "S" or “T" will be entered with numerical designator under appropriate factor) P U L H E Ss 4 PREVIOUS 1 1 1 1 1 1 PREVIOUS 5 PRESENT 3-T 7] 1 ] 1 ] PRESENT 6 |INOIVIOUAL HAS THE OEFECT(S) LISTED BELOW. (Au defects requiring a3or4inany PULHES factor wil be reported in non-technical language) Atypical migraine with syncopal episodes (_] Continued under remarks SECTION C - ASSIGNMENT RESTRICTIONS, OR GEOGRAPHICAL, OR CLIMATIC AREA LIMITATIONS (Check Applicable Item(s}) INDIVIDUAL REQUIRES NO MAJOR ASSIGNMENT, GEOGRAPHICAL, OR CLIMATIC AREA LIMITATIONS MAJOR ASSIGNMENT, GEOGRAPHICAL, CLIMATIC AREA LIMITATIONS ARE ESTABLISHED BELOW (AR 40-3, AR 40-501, AR 635-40. Describe specific assignment limitations or restrictions as culkned in Chapter 9, AR 40-501.) 8.x Temporary P-3 profile for one year, code F (should be assigned close to major medical facility). (D Continued under remarks 9 THE ABOVE CONDITIONS ARE PERMANENT 4 10 THE ABOVE CONDITIONS ARE TEMPORARY. BUT EXPECTED TO CONTINUE IN EXCESS OF NINETY DAYS, INDIVIDUAL IS TO REPORT FOR FURTHER PHYSICAL PROFILE EVALUATION, MEDICAL TREATMENT OR DISPOSITION, AS DIRECTED (AR 40-3, AR 40-501). THE 1 ABOVE CONDITIONS ARE TEMPORARY ANG ARE NOT EXPECTED TG EXCEED NINETY DAYS. ARE FOR UNLESS 12 OTHERWISE SEPARATION OR OIRECTED (AR 40-501). RETIREMENT OF THIS INOIVIOUAL WILL NOT BE EFFECTED WITHOUT (AR 40-3, AR 40-501, AR 635-40), 13 | X PRIOR MEDICAL EVALUATION: ” - THIS SUPERSEDES PREVIOUS MEDICAL CONDITION - PHYSICAL PROFILE REGORDS 14. TYPED NAME & GRADE OF AUTHORIZED OFFICER AT MEDICAL FACILITY EARL_WASHINGTON, JR., M.D... CPT, MC DA LIMITATIONS NOTEO ABOVE DAYS AND ARE AUTOMATICALLY CANCELLED ON (date) FORM bdul 71 3349 “Fl (Dehernflry REPLACES: EDITION OF 1 MAY 6swi WHICH WILL @E VSEO t V UNTIL EXHAUSTED.