Fares 08
(Rev. Jaume 1056)
RE
L. .AST Bem C—TIRET BAe Bae
BR. ORAS AND COMPOMERT Of POSITION
3. le@emtipcation ao
d. HOME abbagsn (A ube, aed @ BPD, nity & tn, cone od Beata)
$. PURPOEE OF ELAmiMATIOR
mm
@. BATS OF EaAMination
7, oan
10, aerncy
6. mace
©. TOTAL FEARE Govenwuterr eeRvicE
MtLrramy
12. DATE OF DIATH
Sond
a
“_
0G. OTHER INFORMATION
Time im THis Capacety (Totes)
CLINICAL EVALUATION
(Caeckt each stem in appropriate. ook
umn. enter NE’ if not eval
df)
14. wrap, Face, NECK Amb BcaLP
copeeeesecleset
2.
14, mONE. RELATIONS OIE, ASE BBOGEAS OF HEKT OF tin
07, @arine om BPECIALTY
NOTES
ABNOA-
LAFT 81x mwoItns
(Deecribe every abnormality in detail Unter pertinent item number before each
momment. Continues in stem 73 and use additsona! sheets if necessary.)
1B, mont
21, wouTH amd THROAT
22. pane—erngna OUSL
ead Th
23. seuss (Perforation)
24. ATER—OCNERAL Gearceede ot oneer
28. oputnatmoscoric
26. eurica (Bqwahity end reachan)
27. ecuiaa serum A ertated Eaole mo
20. Lunes ano crest (Jmehods bremats)
20. meany (Thenst, sie, rhythm, erunds)
30. vascuLam sretéu (Veriostha. ac.)
31, aboowan awe wrectaa (Jneieds harena)
Items 11 thro Lf not exmined
32. anus and RECTUM ‘Pree U nands
33. cmoocerma nyatem
34. ®u STsTeM
98. upper axvacwrvies eres. rem of
36. rere
37, Lowes extacumies ior
of ntion)
38. petat. otmre mUsCULOaECL ETAL
30. IDENTIFVING BODY MARES, SCARS. TATTOOS
40. grim L¥menarTice
41. WEVRCLOGIC (EewQQetnm ime onde ten OF
+ WOVE MIATRIC CSpesity omy peemesdlep dovkation
he
ae
11, O@eanumation war
Civilian
08. pace OF GiFTH
TB, CRAM INInG FACILITY OR ELAWINER. AND SBDaTES
Ere
PRIVACY ACT MATERIAL REMCUS:
TIC,
. PELVIC CPemalee ondy) (Chant how dons}
CJ vacrear (0 accra
(Continwe in ttem FS)
44, etmta (Pisce approprials qymbols above or below numer of upper end ieee teath, prpectoaly.)
— Rastorable lesth
T—Minag ieath
fueNenrestorehle inath
A
4
1
H
x
T
r
1
(0X H—FPiuzed widge, breackas te
YYY —Reploced by dente
4
5
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a
2
Sed
F
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om
REWLAED Ant ADBrTiOma, DEMTAL
DEFECTS AMD DISTASES
teolwds Soules
10
W
12
2
am
.
13
14
18
L
aber
ts
1.
roof
T
LABORATORY FINGemcs
45. UaimaLyaiS-
a
a. SPECIFIC SEaviTy
a.bumin
46. Coeat x-may (Pines, date, Alm numer end rarutt)
G. micwoscoric
€. tuésa
47. scaovos: (Specn/y tat weed and rerulf)
46. nreé
40
L600 Tret amo an
$0, piaae Toms
Facton
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED