AL DOR AAICT
PRIVACY ACT MATEP!
Gtandetd Farm &
(Rev. Juse 1056)
REPORT OF MEDICA® EXAMINATIC.<
4. LAST WAWE—FINET NAMES IODLE RABE
2. GhADT ANO COMPONENT OF PORITION
2. iDaetieication mo
& wot aponkss (Nembe, atred or BF D, ody or own, cons ond Sinise)
@. puRPoOr oF flamemation
@. eave OF akamination
7. oar
-
f@. mace
{s. TOTAL TEARG GOVERNwreNt Stevice
j@urrany
12. BATE OF sl6ta
10. setacr
13. PLACE OF BIatH
14, RANE, BELATIONSHIF., ANG AGORCES OF MEET OF Kin
15. ERAWINING FACILITY Of EXABINER, AND ABDATSS
16. GTHER INFORMATION
17, GATING Se BeECIALTY
be be ba be be be fa he he befell
feds
m
viee am ves capactry (Teta!)
LAST Bsr woerrms
|
CLINICAL EVALUATION
(Checa each item inappropriate col
umn, enter “NE if not evaluated }
won.
BL Ta CO
= wars
11, omeamizartion vane
crviLian
apnoea.
wh
NOTES. (Deecribe every abnormahty in detail, Enter
pertinent item nm
comment. Continue in item 73 and wee edditional aheeta if neceseareore ench
V8, MEAD, FACE. MACK. AWB BCALP
20. aimuvecs
21, woyTH Amp THROAT
22. cans—ernyea, OSA. peel bee Ty
23. onuas (Perforaien)
24. CVEI—et nena, SOUee ee cna
Z4. OPHTNAL Mosc OrIC
26. pUPiLs (ZF qwality end reaction)
27, OCULAR worierry Asoteletpeeke me
28, Lumes ano cute Uncluds eosts)
Ze.
maaat (Tarwst, ape, rhptim, sounds)
20. vascuien aretzu (Varwcomhe, oc)
ws
31. secomem ano wincens (Faotude hernia)
Items 31 thru B@ not exanined
.amve ane accrum YmerMate,fowtes
33. enpoceme svitece
. &u SvsTin
.
-~
3
BORaia hh MEE
38. vrrce cxrenwcies eee. rene
34. reer
27. Lowne crragwstigs eeoy medi
5
+ RPE, OTMEE BUBCV LOSE EL ETAL
3 + IDENTIFYING S007 MARES, SCARE, TATTOOS
40. skim LrePuaticn
41. WEURGLOGIC C&eutkietmm any pele ee TF
~
4
+ PRTCHIATENC (hm damp per imei deen:
- wtivic (Pomales only) (Check how dons)
Co waGinay Oo aactar
-
*-
-
*
~
.
.
16
BJ
a
»
a
2
a
a
2
ta
a
W
12
43
14
48
‘6
2
nm
2
1
le
wv
BEMARES AND ADDITIONAL DENTAL
DEFECTS AND SiStants
Aaa
mS
LABORATORT MADINGE
45. Uaimalygis
O
ok Shag amaeity
slLhuMia
46. Hest nemar (Pisce, dats, Alm numinr and resull,
GO, MICMOSCORIC
€. SuGaAn
“a
¢™
en
a
re
<
ae
ee
=
$0. OTHER TESTS
Factor
C
#)
49 BLOOD TYPL Amo am
v7
4a nce
=|
Y>
47. ateovoéy (Specsy tert wad end rerud)
w
rT
2)
:
~
5
(Continue in item 74)
44, pantay (Place approprau eymbols show oF below number af upper and lower Leath, paspectisaly }
(6XFused brutes, brackets le
X= Msssing loath
O— Remorobly teath
{=onresiorable isath
IY — Replaced by denture
include sinainends
ArO-—2
.
PRIVACY ACT MATERIAL REMOVED