CP SaEE PRIVACY ACT MATERIAL REMOVED Sesedeed Ferm & (Rev. June 1986) RE | 2. Gnade Ab ComPomtw oR POErTIOn 4 WOME AnowEs 121 wee, — olor BP D,city o& town, eons and Sais) 6. PuRPoEr OF ExAmepation 7. ats @. @act | B. FavaL TEARS GOVERNMENT SERVICE | wirtaer 12. @aTE OF BIRTH 10. agrner Pere 43. Peace OF GiATH @. DATE OF EXaw|maTioN 11. @meanitation unr uJ 4 1d, SAME, RELATIONSHIP, AND ADORESD GF MET OF cin 16. QGTMER INFORMATION 17, GATING OM BPECIALTY Time in THis cavaciry (Total) CLINICAL EVALUATION y doktor dokbdb b ba EE |" IBERTIFICATe TO Civ thin th. SRAM@IAING FaCiLrry OR EXAMINER, AMO ADDRESS Pa ¥ gga EE INATIC . L 1. LAST GAM E—HFIRST MAGE —EODLE WaAeE (Check each siem in appropriate cok umn: enter ‘NE’ if not evelyvated} 18. MEAD, PACE, ECR. ANB CaP abwon- LACT #1% woNTHs NOTES. (Describe every abnormality in detail. Enter pertinent item aumber bafore each eomment. Continue in item 7) and use additonal sheets if Mecesesry.) wa 18. wose 20. Binuaee 21, BOUTH AND THROAT 22. came—ecwena, ONOeeovate ey. 23. onums (Perforation) 24. UVCE—O EWEN teed ona eeets ee eee 75. oewrnaLwoscore 26. Pure (RB qwality end peachon) 27. ecusas wotiirry meted peels wee 20. Lunes anp corset (Uf nebeds breoats} 26. wcaer (Farwal, mre, rAythn, erunds} 30. vascuvan srerce (Vaercomhes, ac ) 31, aspomem amo viscias (Jnalude hernia) Items TD thru L2not examined 32. anus Amo fecTye (Beetece, rye rt 33. tupocamt srsvtm . 34. @-u BYETIW (Seong eengs of 33. UPPER CATREWITIES gain, ~ 37. Lowra GarmemiTiah Eeeoe eeetme) 20. SPiN. OTHEe mUsCULOBeRL ETAL 38. IDENTIFYING BODY MARES, SCARS. TATTOOS 40. Gkim Leernatic® 41, MEUROLOGIC LEethhnterm tetts wmter dim PP 42. FRYE MIATAIC Cipenty cmp per emahay domemen) 43. Peiwic (Females oly) (Check dow dows) (Continue in ttem 7S) Oo ELI LIS O) RECTAL 44, orate, (Pisce apprepeais qymbals abcer or below number of upper and lower loath, rea pechoeiy } (6X \— Fired bridge. | O— Reatoradls tenth X— Af aang lerts ® c 1 2 " a n 4 x» YY — Replaced by dentures 4 a 4 7 a 9 vp 28 za Fr.) 23 | nm hats to Rem saEKS AND ADDITIONAL DEFECTS am OtSLaBls DCMTAL seeciuds etutmente 1D "1 a 12 iz 4 15 18 aon x it 16 17 49 Re (—Nonrenorabls tasth ae ge PEAAROS « CAPEABeet ent a 36. rant LADORATORT FINDINGS 45 UmieaLyert B SlLiUwin Cc Suéar oo 46. corset a-mar (Place, date, Alm numer and rerull; SPECIFIC BRAWITY 47, ptaoLocy (Specify tert used and reruit) G miCMascoric 48. oKe 49. BLOOD TYPE AND Ry Factor $0. otHEA TESTS BEST AVAILABLE COPY 3 4 ' VED ATERIAL REMO PRIVACY AGT M