nevdeneiba)
e
RE
PRIVACY ACT MATERIAL REMOVED
ATIO ’
1. LAPT MAGE=F1GET HA EDIDDLE ANE
2. @nabE AND COMPOREHT Om PORITION
3. IDENTIFICATION a0.
‘
i;
& mont aboncss (Numba, are or BF D, sity o¢ town, poms and Mints)
B. PvaPosE of Examination
7. Onn
(@. agency
“Sf
py
~
x 4
4 part'or manne? ris
MIS
@. maci
{s. TOTaL TEARS SovEnRMENT geRvict
{ wicrrany
.
$8. BATE OF BinTH
11, @ROANIRATHOR WRIT
—
jews
13, PLACE OF BintH
b4, MAME, RELATIONT NIP, ANG ABOREGE OF HEXT OF fin
&
4
1. CHAMINING FACILITY G8 EXABINER. AND apentse
b
$7. MATING @8 B>ECLALTY
k
aoa.
oBAL
‘i
*
a
14. oTnEe infomation
Tiwe a Fuis caractry (Tatal
LAnT 61 wowtne
|
(Check TS cok
umn enter NE if not evaluated)
zy
10. HEAD, fact. mEcK, AND scale
s
>
(6. ose
z
Xf
abnon-
was
l
mores Gomment.”Continue initem13and wassdditoonalshevteWf necweare “en
20. amusis
Fat. sours ana twaoat
Y
tt. canem—cenena, Soeee eeeth,
§
t
x
=
Y
:
Zz
}
23, onuus (Perferahen)
4. evew—erwcna ees, ee cee
y__
*
28. OPnTuaALMoscoric
24. evrice Utewah ty ond reaction)
¥
27. e¢unas woriurry teed mew
¥
20. Lunes ano Cars (Jnatude brepats)
¥
28. wcant (Thrust, eine, rhythm, eons)
¥
26. vascuian sveten ( Ferisscifies, a.)
31. aspomem ane wiactta (Smcbeds harvas)
Items 31 thru L2 not examined
32. anus ane aectun —* U tetenard)
13. cacocaint sverce
34. @u sritiu
(Pereneth, vanes of
38. VPPLe CXTACUTTIEE meee)
™
36. tt
LOWES CITREMITIND pores
tenes af muanten)
36. SF1mC. ormga wUBtULOBRELETA,
30. REWTIOVING BODY MARKS. SCARS. TATIONS
40. SEIN LYmenaticn
41, MEUMOLO8IC Cpetteteme Gens ender dim PR
42. CRTCHIATRIC Giparlty oem or nrmeder donee
43. penvic (Females oaly) (CAack Aw dons)
~
3
©) vacinae OD wectac
(Centinue in item 7X)
44. puta, (Place appreprau mymdols abee or below number of upper end Lower leath, res partially)
O—Rastoradle tnsth
T—Misnng toa
{/—Nenrestoradle inath
é
H ®
n
>
oa
w~w
(6X Fp—Pined brides, brecketa we
TTT —Replaced by dentures
ew
et
norm
ele
lM
1o0U
p
lg alatmanete
118
Pisin
Ww
14
1
16
as
10
1s
WW
MCMAMED AUD AOOTTIONAL DERTAL
SETECTS ANP Sleeaate
49aar
:
LADORATONT Fimorecs
45. Umimaivsis:
46. cutest a-aay (Pines, dads, dim number and rerult)
@. OPEcific @aavity
B ALBUMIN
B. mIgRORCOFIC
c. fugaa
47. sttoLoer (Specify test used and reruil)
ab. cre
46. BLOOD TYFE ane Am
Fact
$0. otate TEsTs
fe Aad.
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED
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