MENTS
Ol. mavexr
82. wrient
a7.
G3. CoLom Hala
G4 cocoe eres
Bice pacapune (Arm of haart inet)
4,
Tt
ermine
a8.
{
5.
ry
orn.
oret
oiat.
atcun-
ous.
OD esesee Cleese Olan
ova.
(8 on.)
cas.
& efrrnne
60,
O06, Trmraearues
( osees
oviss (dew af heart lal)
oe.
e.
GTanbding
WETANT Visto
BG. ours,
G&. AFTER BREACIOR
warhaction
& @ Gin. arrea
O. RECUMRLET
et.
|G. aFree STaAncing
ama.
WEAR Vibton
alent ae/
gera. To 807
w
a.
ox
conn. To
ay
Laer tos
Come, To aes
wv
iy
on
cOmk. To
ay
SL. wrtieopnonia (Spensy dist)
as*
63.
ax*
an
accomwoparion
Rien
ue
Pase piv,
pase Cony.
eo
we
4. Coton vision ( Tet weal and resell)
65.
pyere at
pencerrion
pee
ar
)
67. mlent vision (Test weed and seers)
68. RES Lins rest
.
| vacoaaecrao
cert
connecree
$6. FIELe OF visION
70.
rf
TI .
WEARING
SieHT wy
fiw
fis
Leer wy
(va ov
fue
AUDIOMETER
190
as6
goo
oi18
1000
1084
s000
O048
09. uttasccULan TaNmion
TR. (Fea
PEYCHDLOBICAL
a AND PRYCHOMOTO
;
oror
soto
a8pe
soce
M068
seco
814g
sone
:
B108
ent
*
tery
73. mores (Conmaeed) and SIGNIFICANT OR ieTZRvaL MisTORY
dn 39-PD radiationt.beS to mr/hr, not above background
(Ues eilditional sheds if nassocary)
74. SUMMARY OF DEFECTS ano BiAGnosrs (Laat diagnose: wah iow members)
75. RECOMMENGATIONS—FUNTHER SPECIALIOT Examinations sapicataen (Specs/y)
76,
&, PHYSICAL PROFILE
e
u
L
*
e
5
77. examinee (Check)
& Das quaurico ror
B. PHYSICAL CATEGORY
o. 6 ts wor auauirine ror
70. UF WOT QUALIFIED. LIGT DISQUALIFYING DEFECTS OF ITEM BUMSER
76. TYPED OA PRINTED RANE OF PHYSICIAN
CARL EB. HANSEN, Lt Col, USAF, MC,FS
a
e
e
©
srenaTuRE
OO. TYPED Of PRINTED WANE OF PHYSICiAn
Sienaryae
OL, TYPED Of PRINTED HAME OF DEWTIET OR PHYSICIAN (/mdhoais which)
sremature
02. TYPE OF PRINTED MAME OF REVICWINE OFFICER OF APPROVIN® AUTHORITY
BGnATURE
NUMBER OF aTTACHED SHEETS
U. 6. GOVERNMENT PRINTING OFFicd
ISET O—ehhate