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PRIVACY ACT MATERIAL REMOVED
oO.
REPORT O
Gov uneTose)
Seandard F,
‘
1. LAST MAM E—FIRST Game —mOPLe Bane
2. GRAGE AND COMPORERT Of POSTON
3, sDEMTIFICATION HO.
=
& nour asencel Wunbe,ares or BF D, city or tron, cons and Stata)
6. Puwerose oF Erammazion
6. GATE OF Examination
:
7, O&X
11. @ROANIZATION ear
10. aeancr
; O. Tota, YEARd GOVERNMENT PEeviCE
®. aaca
.
as
7 aa 58
{ civinian
mourrany
16. WAGE, RELATIONSHIP, AND ADORERS OF REET OF HER
U3. PLact of biirtn
12. BATE OF BlaTH
;
1B, SRAM INING FACILITY Oa EXAmINGE, OUD RDORESS
16. @THER InroRmaATiON
-
a
4
CLINICAL EVALUATION
da Hehe fe tate te a bh be be ab
are
Tag agpIREI ae
2
:
Tit ie tare capacety (Tatel)
U7, aavine Of SetcsaLTY
NOTES.
(Checd each ttem in appropriate cok
umn: enter *'NE” if not evaluated }
abnoku
|
(Describe every abnormality in detail,
semment,
LAST SIZ wortes
Enter
rrinent em number bef
Continue in item 73 and wee odditional sheets if necessary “oe ooh
18. mGAD, FACE. Meck. ame ecaLP
18. moue
20. ermvecs
25. MOUTH AMD TuROaT
22. rans—erncaa, Us
‘A meaey
23. pavas (Perfareiwn)
Ciena! peweny amd oy fresien
2a. Orth einteay weer tere 48, ee end 8}
28. opwrnaLmoncoric
24. Perice (Equality end renchen)
27. ecuLae motiirry oeeted
perio meme
8, Lunas amp cursy (Jmebuds breusts)
20. ntaat (Tarwel, aise, rhythm, sounds)
£0. vascuLan svatce ( Fertcesshes, alc.)
31, aepowan ame viscosa (Jnehude hernia)
‘
Bt. anus ane eacrue (Romereh,tee
2
23. aspocaen svetew
2
34. @u BvSTOe
Ttems 31 thru L2 not exarined
98. urece exvacn rigs Sone. cones
'
36. reer
:
37, Lowen ervecurtics Borel
tgs of mation
;
“
38, SPimt, OTHER wUscULORAcLOTAL
.
29. \OCHTIFTING GoDY WARES, SCARS. TATTOOS
.
40, mim ymenaticn
x
41. MEVAOLOSIC Cmptiirtem tome wader doe
4
42. PRTCHIATAIE CSpeetty my puremmaliiy dieviadion!
7
43, etivic (Females only) (Check how done)
CO vaca: 0 nectar
4
i.
f
{WN enresterebis lads
t
i
t
H
T
(6X 0)—Pined bridge, breckads ta
T—Msssng tonh
O—Resorabis sesth
R
é
:
(Contines in trem 7S)
44. Genta, (Place appreprads symbol: eho oF below number af upper and lower tenth, rerpenheay.)
3
ax
TYY — Replaced by dents
4
6
$
tt
bel
?
8
BEWARE AMO ADOITIONAL OENTAL
DEYECTH ano ouncants
secluds efutmenta
?
40
Ww
Ww
uw
4
1B
1
Fad]
pn
Ren
Pt]
te
1a
ws
L
=6f
6UF
T
LABORATORY FINDINGS
48. Ueinauverns
46. Cust xeaat (Piece, dots, Alm number ond reruil)
8 SPECIFIC efavety
®. BLOUMIN
B. BICHOSCOPIC
€. SUGAR
@7. sumoroes (Spac/y teal weed and rerull)
48. tee
49. QLOOG TrPT and &n
Facton
SO. otwia Tests
BEST AVAILABLE Copy
x
PRIVACY ACT MATERIAL REMOVED