PRIVACY ACT MATERIAL REMOVED
Sasda Form &
(Rev. June 1946)
NATIC..
RE
1. LAST MAM e—eRET Memes IBLE Waue
mums muemgee ee sireat or BP Di, sity oF tron, sone ond Binis)
. oan
@. mace
O. TOTAL THARE GOVERABENT BERVICE
mLrtaay
12. BATE OF BretTK
2. SRAGE AND COMFORT RT ON POSITION
3. sbeertiptcation wo
B. PURPOSE OF Ehasin tion
G. DAaTR OF ExaminatiON
U3. PLACE GF biRTH
time In Tas capacery (Tate!)
CLINICAL EVALUATION
hoa.
(Check sech item in appropriate col
umn: anter NE" if not evaluated )
apna.
LAFT Sik woWTHS
NOTES. (Describe every abnormality in datas. Enter pertinent item number before wach
aomment, Continue in item 73 and use additional ahetta if necessary
was
14. Whab. Pach. mica. ano scape
18. BOSE
20. simusis
21. BOUTH AND THROAT
iw oepels (A aah sory
22. Eame—semtnay OS,
farms Po ae Ty
2). taues (Perforanen)
24 CVLOOENT RAL ClouseabRoarer
2b. oputmarwoscoric
24. Purics (Equality and reaction)
27. ecucap woviery Ametteied
pevelial erm
28. Lunes amp CHity7 (Include breasts)
2D. mean (Thewat, mea, rhydhn, spends)
3
» VASCULAR OvSTEM (Varcomiian, alc.)
o
some
a
od od wh vd ot od vt wh ot mb ok ob oe
wal
i2
aw
18. OTHER imFoamaTION
17. Rating Ge BeEcIALTY
x
|
26 Fut
14, MAME, GELATIONSNIP, ARO A0OREES OF BTXT OF gin
1B, CLAWINING FACILITY Of ELADINTA. Awd ADDATOS
p
11. OREANITATION YaRrr
10. agency
CoVOLIAN
Bi. Appowsn ano viscees (Include hernia)
fms,
nn
3 - ANUS AND RECTUM
Items 1) thru 12 not exaxined
Aovedes)
een
33. cuooceiat grate
.
3
§
@u britte
.
*
(Serewgth, came as
» URPCR EETRE MITES
ihe
30. ron
37. LOWES COTREMITIES Sorteromps of mettond
x,
26. BPISC, GTMEA MUSCULOBEES ETA,
,
Jf. IDENTIFVING BOOy WARES, SCARE, TATTOOS
40. Stim LrmPnatics
.
41. MEUNSLOGIC Chpatitewen inate ede dam OF
42. POTCHIATRIC Uipemsy ome perermabiy demain?
43. pauvic (Female only) (Check how done)
DO vaca, ( neetar
(Continue in fram TH)
aa. StNTAL (Place apprepeai: symbols ahoer or below umber af upper end Loewe Lasth, rerpactheely.)
~
sp
sey
nore
ele
NN
won
DR
18
a
8
te
nw
1@
18
WV
OLFCevs
amo
BibCARtS
4aane
.-
ht
»
MCw Ahad Ano BOD Toma, DENTAL
IH
X Si —Fised bridges, raskas to
teclide abutments
X—Mvwsine toath
WIT —Replaced by dentures
+
+
LADOMATORT FINDINGS
450 UMIWALYSIS
@
a6. cheat memay (Place, date, Alm number and rerull:
oa. SPECIFIC SRAVITT
@iBumin
6. micmoscoric
€. syugaa
47, atno.oey (Specly tent used and rerudl)
48. one
48. BLOOD Tree amb An
Factor
$0. OTHER TEETS
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED