Age, Varela WTORd og,
1, Last RawemrinsT meet —meeLe wane
8. Ghase 248 COMPONENT 08 POR:TION
3, apqevipicatren mo.
@& mond abpates (Nome, sired or BF_D, sity or own, pens and Mats)
6. PuRPosE @F Elawinareen
@. eave OF Shamination
14. MANt, RELATIONSHIP, AGP ADDRESS OF REKT OF din
18. pace oF binTH
14. @THEA IMFORNATION
T lee
V7, MATING OR BPECLALTY
CLINICAL EVALUATION
NOTES.
{Checd each stam tn appropriate col
*
dededa dete fete te fe ek
RE a
REEEE ye
£4In) 58
jews
miLitser
12. BaTd OF GIFTH
Vi, ea@amizaTioN earT
16. setncy
©. Tova. Vues sovequweer seavict
O mace
.
7. OnX
UB, CRAMIEING FACILITY O82 EXAMINER, Amp AbOhEEE
we
eeoa
x va.
FEETREFTPRGR
PRIVACY ACT MATERIAL REMOVED
:
REPORT OF MEDICAL EXAMINATIO,
Rey dame 1986)
Gueederd Fore
wonn, enter “NE df not evaiuated.)
abana.
wa
|
im Tare caeacrry (Tetal)
Last Gin mOomrHE
(Describe every abnormality in detail, Eater pertunent stem number before each
emment. Continue in item 73 and use additional sheets if necessary.)
U8, MEAD, PACE. NECE. AND BCaLe
26. tunusts
21. SOUTH AND THADAT
£2. gans—ocncna, Ue,oat
ee
23. paums (Perforation)
24. evrs—ermcna, Qs,et oo
25. sewtnsimoscoric
26. Purice (Bouakty end renstion)
27. eCULAA WoTILITY “tender
20. Lumes amp cure? (Fedde brenats)
29. waar (Thrwot, ose, rhythe, eounde)
30. varcucan averce (Varienrthen, atc.)
Items %1 thro h2 not eramined
Bi, apoowen ane vwiecuna (Taahuds herwia)
92. anus ane mecruw (BemerrMpte,Aameless
33. ENDOCRINE BYETEN
34. a.v S78TtM
38. UPPEa extacu rigs C@irengih,
on
tongs of
36. reer
97. LOWER Garacmrricn preety amattens
36. Pint, OTHER mUSCULOSEELETAL
39. IDCRTIFYIng DOO MARES, BCAMS, TATIONS
40, Ouse LrePwaATICS
=
4 + GMEVEOLOGIC ( Kewiintertem gemty ema tome FF)
42. POVCHIATAIC pats emp prreeneiy dometemn)
43. etiwic (Pemedes only) (Chsct how dene)
(Continues in item PF)
D vasswa. 0 anerac
44. pewvay (Place appeeprraic eymbols above or balzu number af upper end lower dash, rerpactioaly.)
O—Raserable tonth
X—Munng tenth
{—Nenrsatoredle teath
R
jt
ez
2
on
23
‘
pe
(OX
M—Posed bridge, brackets bg
YY — Replaced by dentures
8
‘
nn
r
+o
®
es
satlude ehutmenis
wo
so
t
2
W
mf
3
©
1@
6
18
Ww
ACMeRTS ANG ADDITIONAL OLMT AY
PEFLCTE am Bintants
L
te og
wr
T
LABORATORY FINDINGS
43. URIMALYSOR.
Sn ae REal PE TPTea EEY
Rigashthlhe mee Ee ee eter, amc ee ctl1a bgcenaaer agen ne
46. cmrst a-ay (Ploce, date, Alm number and rerutt)
Bo BedCIrIe @eaver
6. aLeyain
bo. micaoecoric
Cc. sugar
47, scmoLoey (Specify tert weed and rerult)
a6. axe
40. sLoop TYPE ano Rw
PacTon
90. OTHER TESTS
ettert©F3.3
Ly
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED