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.