PRIVACY ACT MATERIAL REMOVED
REPORT
U, GAT mamF iE RAE IDOLE AAwE
2. @aAbE bad COmPoOmERY OR MOETTION
3. IDASTIFICATION WO,
4& nowt apodhss(Numbe, otras or BF D, aly or tron, bend end Sala}
5. Pu APoRE OF GMaMINATION
@. BATE OF ERAmination
me
ted Ce
Beanderd Fore &
(Rev. June 1956)
a
¥
7. ear
|e. rora, vena eoveanwen srevice
@. aact
&
10. a@tncr
V1. Gheamsration yarr
2630) 58
{ Biliraty
BR. PATE OF gietH
‘
42. PLACE OF BiatH
14. GAME, RELATIONSHIP, AMD AODRESE OF MEXT OF ZIn
46, GRAwWINING FACILITY OR 21AMINER, AND AGOALEE
$6. CTNER InFORmATION
Yume tN tos caPaciry (Tata)
17, MATING Of BPTCiLTY
CLINICAL EVALUATION
ie
-_
=
alalalalalalalelalalatala
ete
NOTES.
(Chech each item in appropriate oolume enter NE’ if nor evaluated )
ABNOR.
GAGT 81 monTus
Enter
pertinant itam number bef
Continue in item 73 and use additional ohwets if neosesary) neck
(Describe every abnormatiry in detail
wa
1B. wad. FACE, MECH, aN SCALP
20. sinuses
21, sOutw AND THROAT
22. cams—eentaal ONO ee eee th
23, pauus (Perforehen)
24. vest n nay (cee!Sete, ond safe sctes
« GPHTHALMOSCOPIC
. Puriis (3 guality ead eenctien)
27. ecucat weriiry Ameraied aw
20. Lvees ane crtet (ineluds berets)
28. scant (TArwat, os, rhythm, srunds)
30. vascucan gvatem (Vercecihe, ac.)
31, ascowrn ane viscres (Jnelude hernia)
Items 31 thro h2 not examined
etds, date ine
32. ANUS ano aCcTu
«ed ret>
. TEMBOCRING BtETEM
*
34. 6.0 svetee
25. ueeen extace ities Ci
eeengit. renee af
34. Fre?
37. vowea crrecerics oe, ot momen
SB. BFInd, OTmEm BUSCULOSRELEAL
38. IDCATICTING BODY MARES, BCARE. TATTOOS
40. gain Lverwaticn
41. MEUMOLOGIC Uipecietrn camp we diss PF
~
4
» PETCHIATAIDC Ulery ome ‘per eemebey dreds
i?
4 . Peivic (Females only) (CAeck how done)
CD vaca. [) meer
(Continue in item 77)
44. twa, (Place appropriate qymbols adowe or below number af upper and lower teath, rerpertitaly )
X—M vasing oath
@CMAAES amd BODITIOMAL BEwTAL
GUFECTS su DISEASES
nelwds abutments
~~
-
es
*
-
a
=
R
1
G
La!
T
(f X N—Pised bridge. brockats to
YYY —Replaced by enteres
f— Noms satorabls teats
4
18
16
aD
8
7
a'r
O— Rastorable tests
LAsCaaTOR? FINDINGS
@5. UMIMALTSIS
46. Cust a.nay (Pioce, date, Alm number and resuil,
4. PECIFIC Om a¥ITY
6. aldumla
B
MICRORCOPIC
Cc. sean
a manste b oF
wee Teetheee
47. BrAOLOG, (S pecrty best weed ond rarutt)
a0. ara
45. Biocon Fred anp an
SG. oTrwae TESTS
PRIVACY ACT MATERIAL
REMOVED