Ouadand rom ue
(Rav, June 1686)
4.
REPOR
C, gAST MAM E—FIAET BACH IBOLT Bae
8. Gnade ano CompontmT Of POE TION
3. ipewTiPicaTioN ao.
PVE nwuntes se eee, aoe wr ow FD, oily oF town, one ond Binle)
5. PvaPos! oF EnamiqatioN
6. BATE OF Examination
}
f
.
i
7, oEK
.
{oe wece
L
-
.
O. Forel Ttans GovaanmgaT BeRvice -.
ii
weurraar
4
42. bate oF piaTH
19. seancy
14, MAME, SELATIONEHIF, AND ADDRESS OF WELT OF E18
16, @Tuge imroRmaTtion
tY. marine Of SPECIALTY
Time Im Tels casacery (Tatal)
(fheck le SE
OT HA wOwTHE
NOTES. (Describe every abnormality in detail, Enter
pertinent item number bat.
eomment. Continue in item 73 and mas additsonal sheers if flecessary wore each
Taenon
umn, anter ‘NE if not evaluated }
a
-
date tela te dete be ba de ba be ba
road So es EBLE CERO: ie fo AE tg 4 cena
26 Jul 58
11, @ROANITATION Gmrt
jcrviuian
13, PLACE OF BIETH
1B. EXAMINING FACILITY G8 EXAMINEG, ANd apeates
ma
40. MEAS, FACE. MECK. amd Stace
21, movte ane THROAT
22, eane—semtaa, So,Thelms be cae7)
23. eaums (Perferation)
24. evee—menn Ema Le ond catredinem
25. oeethalwoscoric
26. purice Ulgeatity ond rencion)
27, OCULAR moTinery Liscutesed
elie! mon:
Lures sen cucet Uinaluds brensts)
- meant (Thewal, ose, rhytim. eownds)
30. vascucan srstem (Farwecthes, ef.)
31. apoomen ane viscuma (imahude hernia)
32. aeus and mgcrys {Pomemite,Bemtoe
Items Sl thru L2 not examined
we
RSETERRIAty ETNERNIEYEOIRT Fo
PRIVACY ACT MATERIAL REMOVED
lee
32. CHDOCRKING STETCH
a4. @uU srstce
3
- VOPER Exvecurtion (Seseee. vemos af
.
at. eet
:
37. LOWER RITACMITHED foray emntiond
3G. GPinE, OTHER BuECULOsediEtar
4 - IDENTIFY§RG GODT MARES. SCARE. TATTOOS
>
. BEIM L¥MPHMaTICN
41. MEUMDLOEIC Cette cents ender Ge TA
»
42. POYCHIATALS Laeenty enw per enetiog doers)
3
43, ecivic (Females only) (Check how done)
R
Oo vasiuar DO avetay
(Continues in item 73)
44. ecntay (Pincs epproprats symbols ahow of below number of upper end lower sesth, reepectiealy.)
O—Restorahis teath
X—Mvseing test
(eX —Pised bridge, brackets to
{—Noewresterahis tasth
:
n
é
1
t
, zn
3
WIT —Repisced by dentors
a
bop
&
é
?
ere
6
|
t
eh
SCMARED AND ADDITIONAL BEMTAL
DETECTS ANG GIBCABES
teat ebuamernts
to
1t
ep
12
eR
13
TT
18
L
le
De
LABORATORY MaOINGE
43. UmimALTSIS:
ta
B
aleve
ec.
susar
a. OrECciriC qmavetT
47. traovocr (Specr/y tert weed and rerutt)
46. cwCet xemar (Place, dale, Alm number and rerwll)
B. micMoscoric
40. cre
49. BLOOD TYPE AnD AH
Factor
SO. OTWEA TESTS
BEST AVAILABLE Copy
PRIVACY ACT MATERIAL REMOVED