PRIVACY ACT MATERIAL REMOVED GQeeaederd Form © (Rev. June 1656) REPORT EDI .. 1. AGT RADE FIAST MAME OTRO RANT £. Gmapt Ame ComuPonecet ce Postion 2. IDERTIFICATION WO. & wour [Cepansn (A eae, arent or BF D, ally o town, sens ond Btnls) 8. Peuneos: Of Examination 6. DATE OF Cham RATION ¥. ace 10. asnct @. nace /e. TOTAL YEAes SOvCRawEWT aeeviCE meeraae 14. para oF sietH 14. WAGE. BELATIONSHIC. ABD ADORERE OF BETT OF Kin 16, otace imroRnaation U7. marine @8 aPuciaLty ae a eae ao ol —24_Jn}_ 55 | crvinean V2. PLACE OF B:RTH U8. CAAmIMIAG FACILITY O8 EXAMINER, AND ADOREDS he 1), epeamiatios var Time im vars capacrry (Fetal) NOTES. CLINICAL EVALUATION (CAecd each item in appropriate column; enter NE" if nor eraiusted ) asnoe. (Describe every abnormality in detail Catt 81K meted Enter pertinent fiem number bel e2nment. Continue in ftem 73 and wee eddnsonal aheots necessary _. onch wa 10. rae, Fact, MECR, awe ecayP 21, SOUTs AnD THROAT 22. cats—~eemcna USOTLtens SentTh; 23. prums (Parferatwn) 24. evds—erncaas peersmaa 28, oPetTHALMoscoPC 26. eurits (Bemahty and reschen) 27. ecuuan sorirry Sete al! moe 20. cumes ano const (Jacluds brenets) 20. weanr (Taewet, eins, rAytin, arends} 20. vascucas aretem (Varicenies, atc.) ® 31, apoowcn ane viscraa (imebude hernia) items 32 thro L2 not exammed 32. AWUS AND RECTUM iRoMt ‘nneind) . 33. cmpocking svavee 34. &-u OTSTEw 38. Grere extaceyes tore. me of 36. rerr 37. cowce exragmrries Som ay mets 36. SPINE. GTmame MUSCULOSKELETAL 3D. IDENTIFYING BODY MANES. BCARS. TATTOOS 4 - BRIM UVePwATICS @1, MEUROLOSIC (Kewthimtam tents emder Saou PY Lod 42. POYCMIATRIC URnamty any puremesiitp devinmem 43, patiwic (Females oly} (Chant how dons} D vasiwa. CF) ezerac (Centinus in item 75} 44. ecntay (Place eppropreats eymbols abow or below number of upper and Lower Lasta, rerpecealy.} (0X M—Fused bridge, bractats to X—M seins beath O—Restore: tath YY —Replaced by denteres simeteedle Sdnatevee . é * 77 a 7 4 ER 6 a ? Ree 8 9 16 WwW 12 a a | eB RB eee 18 +28 r fx—Nenrestorable tasth MCMORES AUD ADBITIOMAL BEMTAL BCPECTR ARO DISEAGKS LABORATORY FwpINGS 45. uiimauvac® © oa BPtCuRee @RaviTy steven 46. cucet n-mas (Place, date, Alin number and rerud) ©. mic MOeCOrC c. susan 47, atmo.ogy (Spanfsy bee! weed and rarull) 40. cue 48. BLOOD TYPE AND an Factoae $6. oTWan Tests ga rie hn ey . al 7 Ne EH Dial at i . BEST AVAILABLE COPY PRIVACY ACT MATERIAL REMOVED