CP SaEE
PRIVACY ACT MATERIAL REMOVED
Sesedeed Ferm &
(Rev. June 1986)
RE
|
2. Gnade Ab ComPomtw oR POErTIOn
4 WOME AnowEs 121 wee, — olor BP D,city o& town, eons and Sais)
6. PuRPoEr OF ExAmepation
7. ats
@. @act
| B. FavaL
TEARS GOVERNMENT SERVICE
| wirtaer
12. @aTE OF BIRTH
10. agrner
Pere
43. Peace OF GiATH
@. DATE OF EXaw|maTioN
11. @meanitation unr
uJ
4
1d, SAME, RELATIONSHIP, AND ADORESD GF MET OF cin
16. QGTMER INFORMATION
17, GATING OM BPECIALTY
Time in THis cavaciry (Total)
CLINICAL EVALUATION
y doktor dokbdb b ba EE
|" IBERTIFICATe TO
Civ thin
th. SRAM@IAING FaCiLrry OR EXAMINER, AMO ADDRESS
Pa ¥ gga EE
INATIC .
L
1. LAST GAM E—HFIRST MAGE —EODLE WaAeE
(Check each siem in appropriate cok
umn: enter ‘NE’ if not evelyvated}
18. MEAD, PACE, ECR. ANB CaP
abwon-
LACT #1% woNTHs
NOTES. (Describe every abnormality in detail. Enter pertinent item aumber bafore each
eomment. Continue in item 7) and use additonal sheets if Mecesesry.)
wa
18. wose
20. Binuaee
21, BOUTH AND THROAT
22. came—ecwena, ONOeeovate ey.
23. onums (Perforation)
24. UVCE—O EWEN teed
ona eeets ee eee
75. oewrnaLwoscore
26. Pure (RB qwality end peachon)
27. ecusas wotiirry meted
peels wee
20. Lunes anp corset (Uf nebeds breoats}
26. wcaer (Farwal, mre, rAythn, erunds}
30. vascuvan srerce (Vaercomhes, ac )
31, aspomem amo viscias (Jnalude hernia)
Items TD thru L2not examined
32. anus Amo fecTye (Beetece, rye
rt
33. tupocamt srsvtm
.
34. @-u BYETIW
(Seong eengs of
33. UPPER CATREWITIES gain,
~
37.
Lowra GarmemiTiah Eeeoe eeetme)
20. SPiN. OTHEe mUsCULOBeRL ETAL
38. IDENTIFYING BODY MARES, SCARS. TATTOOS
40. Gkim Leernatic®
41, MEUROLOGIC LEethhnterm tetts wmter dim PP
42. FRYE MIATAIC Cipenty cmp per emahay domemen)
43. Peiwic (Females oly) (Check dow dows)
(Continue in ttem 7S)
Oo ELI LIS O) RECTAL
44, orate, (Pisce apprepeais qymbals abcer or below number of upper and lower loath, rea pechoeiy }
(6X \— Fired bridge. |
O— Reatoradls tenth
X— Af aang lerts
®
c
1
2
"
a
n
4
x»
YY — Replaced by dentures
4
a
4
7
a
9
vp
28
za
Fr.)
23 | nm
hats to
Rem saEKS
AND
ADDITIONAL
DEFECTS am OtSLaBls
DCMTAL
seeciuds etutmente
1D
"1
a
12
iz
4
15
18
aon
x
it
16
17
49 Re
(—Nonrenorabls tasth
ae ge
PEAAROS « CAPEABeet
ent a
36. rant
LADORATORT FINDINGS
45
UmieaLyert
B
SlLiUwin
Cc
Suéar
oo
46. corset a-mar (Place, date, Alm numer and rerull;
SPECIFIC BRAWITY
47, ptaoLocy (Specify tert used and reruit)
G
miCMascoric
48. oKe
49. BLOOD TYPE AND Ry
Factor
$0. otHEA TESTS
BEST AVAILABLE COPY
3
4
'
VED
ATERIAL REMO
PRIVACY AGT M