MEASUREM $1. werent 62. waent . $3. Coron wan BLOOD Pressuae (drm at haort lead) a Ba. GTHER FINDINGS $4. aulio. 04. rrepewarues D suenpee DD mtcwe 87. artina AND B4. COLOR EYER ars 6. arcum. INT bial fe ave | ee. C. OUTANT VIBION C1 onnse puis (Ares of haart ional) a. Sitting ra STANDING Bias. (3 mem) Clea B. AFTER ERERCION C.F Min. AFTER G. RECUMBENT #0. REFRACTION @1. uotn. WEAR ViBIOR RIGHT 20/ Coen To gos CM 5. or CORA to Lory Bore FO g0/ or 4 oa coAA TO ros L. AFTER Francine dias. br OZ. wevenoenonia (Specnfy demiancs) as? £3. tx* Rw. accommobaTION hiGHT cient wy Ley av PRIsM Biv. Page CONY. eT c as. perm PEOCEPTION O7. mien vision (Test wend end score) 60. ato Lies reer ial 71 . HEARING fis ay wis av ) *o wacoanecten COMMECTED 66. FIELD OF VisION 70 . ue 04. COLO’ ition (Tew uacd and result) fue ne AUDIOMETER z50 B56 $09 iz 1000 1024 sooo 9048 OD. cwrkaocuLan TEnaion 72. (Teme PETCHOLOGICAL mau AND PEYCHOMOTO , R sooo S896 ao00 4006 enco 6144 sooo 8168 acer ” tn 73. moTze (Comhaued) and SIGNIFICANT OF INTERVAL HISTORY Using bete-gauma survey meter MI-S, background reading .03-.06 ar/hr. No radioactive contamination found, (Use additional sheats if necmsery) T4. GUMMARY OF DEFECTS AND Diagnoses (lsat diagnose wih vem aumiers) 7S. MUCOMMENDATIONO—FURTHER BPECIALIST EXAMINATIONS embICATEO (Specyy) 74. A, PMYEICAL PROFILE L * 77, quamingz (Cheok) a. © is quatirico ror eo. Oia wor ovativice ror @. PHYSICAL CATEGORY Th. UF MOT QUALIFIED. LIST DISQUALIFYING DEFECTS BY ITEM BUMBEA FR. TYPED OR PRINTED HABE OF PHYSICIAN Si@WaTURE CARL 1, HANSEN, Lt Col, USAFNC =?S OD. TrPRD OR PRINTED MAME OFPHYSiCiaM GIGMaATURE @1, TYPED OF PRINTED WARE OF CENTIET OR PHYSICIAN (I mchonds which) GIGMATURE B2. TYPED OA PRINTEO MAME OF WEVIEWING OFFICER OF APPROVING AUTHORITY | SIGNATURE NUMBER OF AT TACHEG SHEETS »&. GOVERAMENT PRINTING GFFICE: 100) G-—weslne BEST AVAILABLE Copy