Qeeedard For
(Rev. June [666)
REPORT OF MEDICAL EXAMINATIO,
wae uel
1. LAFT SAM E==TIRGT BAM D—"SIPOLE BANE
. 4 moms apentas lAwmbe, cred or BF D, ay of tron, cons od Stats)
6 ance
7. eax
62. BATA OF BIETH
.
ta. TOTAL YEARS SOVERAMENT SERVICE
[ wicrrany
j civiqian
13. PLACE @F aimTn
§. PuBPOnE OF Granimatqon
@. Sate OF EkAmIaaTion
26 Ju) S58
Uf, enganizaTion UT
+6. OTHER INFORMATION
tree bm Tra capaciry (Tatel)
CLINICAL EVALUATION
<8
3. (@ceT IFICATION He.
414. MANE, RELATIONSHIP, ANB ADDRESS OF BEKT OF Ein
07. aatine Of OPRClALTY
pt at ne fe foal vl mal md md on
2. RAGE AND CONPORENT Of PORTION
10. asaucy
18. GEAMIMING FACILITY GR EXAMINER. ANG ASOREDS
(Checd each item in appropriate oof
yon; enter ‘NE’ if not sealueted )
ta. WEAS, FACE, MECE. Ame GCALP
AGnORBAL
LAST Giz BOeTHE
|
NOTES. (Describe every abnormality in detail. Enter pertinent item number before each
eomment. Continue in item 73 and use additional sheets if necessary.)
BOuTh AND TumoaT
onal
EaRi—SEReMAl crnendetomeewes
FT)
Bauns (Perforation)
24.
EVEs—oeene nay ese,ae eae
a.
OPHTNALBOSCOME
. Ovrite (Roualidy ond renehon)
z?.
Oc uLae motivery Eaetated
verelial eo
tumes ane cucet (Jmehuds brosete)
agaw (Thrust, G20, rhythm, counds)
30, wabCuLan grateu (Ferwerina, atc.)
Items 11 thru 2 not examined
an. ABDOMEN ane witctna (/mabeds harma)
a2. ahUS Ane BICTUS ‘hone Y lesen)
EeDOCAIRE GTrTle
a4. vu SYSTEM
.
urree extaremies oe coe oF
Ferr
a7.
towne exvecerics ne ws mete
SPist. Otwre MUSCHLOOATL EAL
DEMTIFVINS DOG? WANES. SCARS. TATTOCE
SEIN LTwemaATICN
ai. SEVROLOGIC (Beuttietee gem ender Gone MH
PRYCHIATANC Cian omy percmnalig éomedions
murvic (Females only) (Chark how dons)
(Continua in ftem 73)
0 WAGINAL D @ecTaL
44, pomta, (Place approprais aymdots abow or below number af upper ead lower laslA, reepechsely )
T—WM isrng loth
(¢X —Fid inidge, wrecks
PPT —Repicced by dentures
=
oF
es
nope
s
le
10
Ts
W
poe
12
™!
QEMARES AMO ADDITIONAL DEATAL
DEFECTS AND DiStAtEt
amedude phutmenis
4
16
1e
nw
449ner
“Le Se MREHeed RS
PRIVACY ACT MATERIAL REMOVED
LABORATORY FINDINGS
43. UmimaLTOie:
46. Cutet n-nay (Place, dats, Aim number and rerutt)
A. SPRCIFIC Gaavers
B ALOoumie
@. MICRORCOPHC
€. busea
47. etno.ocr (Spensy test weed and rerul)
48. ene
49. gLooe TYPE ANG GH
vacy
$6. OTHER TEETS
BEST AVAIL
ASi Ee COPY
PRIVACY ACT MATERIAL REMOVED