PRIVACY ACT MATERIAL REMOVED
oeie
REPORT OF MEDICAL EX
1. Last SAM ReoFikST BAM Te IBeLE BANE
*
& wont Anvaces (Mamba, BP D, oly or boon, sons ond Diets)
\
2. OAAST AND COUPOHEET Of POSITION
3. spamtiecatian wo.
B. PuRPOsE OF KLAgIBATION
@. pavd oF GaauinaTion
wl
'
7. om
a. RACE
®. Tora, Yeaks govenmwesT peavict ”
wrhivarT
12. eaTe oF SuRTH
16, serncy
1B. PLAce OF QunTH
ra
16. @TNaa mrormaTion
17, aatime On SPECIALTY
Tie mm tus capacery (Tatal)
CLINICAL EVALUATION
cach Wis, in appropriate cok
2
72.3%
Suv ee FU
$4. MAME, GELATIONSHIP, ANG APEREEO OF RERT OF cin
US, CRAM INIOE FACILITY OA ELASINER, AND ADDEIOG
som
Bé.
Hi. @eeanitation yart
} ervinian
LAST GIK MONTHE
NOTES. (Describe every abnormality in detail. Enter pertinent item number before each
eemment. Contiaue in item 73 and mee addsfsonal sheets Hf necessary.)
Tapeon
abe Labelle
won; enter *'NE"" if not evaluated.)
TO, MEAD. FACE, MECE, ANG SCALP
19, wost
21, MouTe AND THREAT
22. pano—eenena, CU!ee ery
23, eauwe (Parferahen)
24. rvebernena, (ey, ot rene
25. oPwtnaLmoscoric
6, eveie (Bqwalty ond reaction)
27. o¢uian weriury Soeeied
seca moe
28. Lunes ame encet (iasteds branate)
20, ugawt (Thrust, cies, rhythm, avende)
30. vascuLaa arstem (Varicorihas, alc.)
Items 31 thro 42 not examined
31, aboowrn ame viectaa (Jnabuds hernia)
32. anus amo ngetus (Momerreete,Seteion
33. engocawn svetes
,
34. @u eveves
38. vrece extacesrics Se rae
.
-
36. sar
37, Lowen Exrecerries ies of maniend
28. Seine. OTHER BUECULOBMELETAL
2f. teewTirrine GO07 WARES. OCARS. TATTOOS
40. GRIN LrmPratics
G1, MEURCLOSIC Chnetiintem tts ender Go OH
2. PRYCHIATRIG (Ppeety amy peremmadity dantasiont
43. Pecvic (Females only) (Check how dome)
oO vaciman oO RECTAL
(Ceatinue in item 73)
44, ocwtay (Piece apprepriaic eymbols abooe ar below aber of upper ond lower banth, reepactealy.)
O~Rasterabis teath
X—M sang taath
{4X 2)-—Pized bridge, braskals te
/—Neweenerebis teath
R
4
1
ye
bd
ns
a
FIT —Reploced by dome
4
yp
6
eR
e
?
pe
6
|
®
ele
16
acta ebmarte
"W
2
ee
a
4
Ai
6
Rlwsred amd agdiTIOMAL SENTAL
BEFECTS Kup BiacAgzE
L
6¢
ee
LABORATORT FINDINGS
45. Vaacveis, a. BeEcHric @eavity
Oo.
aALOumin
46. cmcer a-nay (Place, dale, dim number and rerull)
&. micaoscoric
c. Busan
46. tts
4h. piacerere anD aH
QO, oTnta rtets
payers Bay 2aan
47. sanoLosy (Spect/y teat weed and rerulf)
BEST AVAILABLE Copy
IAL REMOVED
TER
PRIVACY ACT MA