Geendeed FP.orm
(Rev. Jans 1956)
PRIVACY ACT MATERIAL REMO
VED
REPORT OF MEDICAL EXAMINATIC .
b. CAST GARE—FIRET MAD E—O1dOLE Gant
2.
& wean apbacas (Namba, siren or BP D, ity o town, cons ond Atala)
#. PwAPost OF ERamugTion
Ty. oar
10. asency
6. aace
®. TOTAL YEAAB GOVERNMENT BrAvict
wicitaar
(2. Bara ef SieTH
i. lagFtiFicaTion mo.
6. oat OF ExAniAaTION
41. e@eanization gary
24 Jr
CR
-
{ ervaian
(3. PEACE OF QiaTH
$4. aAat, SELATIONSNIF. ANG ADDRESS OF NEXT OF Zin
08, EXAM HIS FACILITY O8 Thaminge, Ang ADORTES
16. OTHER INFORMATION
17. GATING Of BPECIALTY
Tee am vais capacrry (Tahal)
CLINICAL EVALUATION
dudaduadacaaa: g
GRABLE ANG COMPONENT OF POFITION
( Check sac. A item in apprepriate co
nor evaluated
umn: enter NE “*
18, ORAS, PACE, WECK. AND OCaLP
agnon.
Last o12 womrns
pertinent ttem number 7
bes
NOTES. (Describe avery abnormality in detail. Enter
eech
aheetle if n.
fomment, Continue in item 73 and uses additonal
ij
te.
BOUTN AND TNEOAT
FARO —OENEAAL 4s Temas Pe aaa Ths
paved (Perferahon)
z4.
CVES—CENCBAL — vue
oom
"ed one ate
OPNTHaLMoOsroMit
Puriie (Fowelity end renction)
a7,
OCULAR moTiirTY Lititated
olla! mane
. umes ane curst (I melude bresats)
weant (Tarual, vies, rhythm, meds)
wascuLam pratee (Varienntem, ec.)
atoowrn ane vieccan (Jmadbuds hernia)
Xtems 3] thru 2 not examined
. anus ane mectum meth,Soi!
emeocaiat Brerte
oy tritia
,
vrrce cxvecurries eee. renee of
elit
37.
LOWER EXTRCa ters Benin of matin)
SPINE. GTMER MUBCULOREELETAL
AIDESTICVENG BODY MARES. BCARE. TATTOOS
. SEM LYMPHMATICN
NEUROLOGIC (Squib tote eer tee
42.
PEYCHIATAIC Cigemnty amp poresneies Gerietiee
4
pacvic (Females only) (Check how dons)
©) waeinat 2 anevar
(Continues in ttem TS;
44. atetsy (Piocs epproprials symbols abow ow below number of epprr and Lower Lasth, respect valy.)
/-—Newrestorable teath
R
uot
H 2
T
t
mn
a
4
bw
{6X)—Pused beidoe, brachats to
T— Missing load
TY3 —keploced by demteres
a
‘
r
cos
oe}.
opps
SCeeacs 42ND ADDITIONAL DENTAL
@CFECTS any Bistasel
Sinelwile aetrads
0
op
18
ep
8
on
ow
of
mo
ot
wo
atanmr
O—FPadorahls oath
LASORATORT FINDINGS
45. utinacysis©
66. cuaet a-nay (Place, dace, Alm aumder end reruit)
A. SOECIPIC @aayity
ALB Ih
| #, Micagscoric
C. sugan
47. sraouo 6°
(Specify test weed end rarulf)
40. tee
4%. BLOOD TYPE amp an
$0, oTmce Tests
Factor
BEST AVAiLagie
COPY
PRIVACY ACT MATERIAL REMOVED