Qeeedard For (Rev. June [666) REPORT OF MEDICAL EXAMINATIO, wae uel 1. LAFT SAM E==TIRGT BAM D—"SIPOLE BANE . 4 moms apentas lAwmbe, cred or BF D, ay of tron, cons od Stats) 6 ance 7. eax 62. BATA OF BIETH . ta. TOTAL YEARS SOVERAMENT SERVICE [ wicrrany j civiqian 13. PLACE @F aimTn §. PuBPOnE OF Granimatqon @. Sate OF EkAmIaaTion 26 Ju) S58 Uf, enganizaTion UT +6. OTHER INFORMATION tree bm Tra capaciry (Tatel) CLINICAL EVALUATION <8 3. (@ceT IFICATION He. 414. MANE, RELATIONSHIP, ANB ADDRESS OF BEKT OF Ein 07. aatine Of OPRClALTY pt at ne fe foal vl mal md md on 2. RAGE AND CONPORENT Of PORTION 10. asaucy 18. GEAMIMING FACILITY GR EXAMINER. ANG ASOREDS (Checd each item in appropriate oof yon; enter ‘NE’ if not sealueted ) ta. WEAS, FACE, MECE. Ame GCALP AGnORBAL LAST Giz BOeTHE | NOTES. (Describe every abnormality in detail. Enter pertinent item number before each eomment. Continue in item 73 and use additional sheets if necessary.) BOuTh AND TumoaT onal EaRi—SEReMAl crnendetomeewes FT) Bauns (Perforation) 24. EVEs—oeene nay ese,ae eae a. OPHTNALBOSCOME . Ovrite (Roualidy ond renehon) z?. Oc uLae motivery Eaetated verelial eo tumes ane cucet (Jmehuds brosete) agaw (Thrust, G20, rhythm, counds) 30, wabCuLan grateu (Ferwerina, atc.) Items 11 thru 2 not examined an. ABDOMEN ane witctna (/mabeds harma) a2. ahUS Ane BICTUS ‘hone Y lesen) EeDOCAIRE GTrTle a4. vu SYSTEM . urree extaremies oe coe oF Ferr a7. towne exvecerics ne ws mete SPist. Otwre MUSCHLOOATL EAL DEMTIFVINS DOG? WANES. SCARS. TATTOCE SEIN LTwemaATICN ai. SEVROLOGIC (Beuttietee gem ender Gone MH PRYCHIATANC Cian omy percmnalig éomedions murvic (Females only) (Chark how dons) (Continua in ftem 73) 0 WAGINAL D @ecTaL 44, pomta, (Place approprais aymdots abow or below number af upper ead lower laslA, reepechsely ) T—WM isrng loth (¢X —Fid inidge, wrecks PPT —Repicced by dentures = oF es nope s le 10 Ts W poe 12 ™! QEMARES AMO ADDITIONAL DEATAL DEFECTS AND DiStAtEt amedude phutmenis 4 16 1e nw 449ner “Le Se MREHeed RS PRIVACY ACT MATERIAL REMOVED LABORATORY FINDINGS 43. UmimaLTOie: 46. Cutet n-nay (Place, dats, Aim number and rerutt) A. SPRCIFIC Gaavers B ALOoumie @. MICRORCOPHC €. busea 47. etno.ocr (Spensy test weed and rerul) 48. ene 49. gLooe TYPE ANG GH vacy $6. OTHER TEETS BEST AVAIL ASi Ee COPY PRIVACY ACT MATERIAL REMOVED