REPORT OF MEDICAL EXAMINATIC..
1, LAST HAME——FIRST MAME—MIGOLE BAwE
2. GAADE AND COUPORENT OF FORITION
2. IDENTIFICATION NO.
4. wend apontas (Noumea, areata £ FP D, aly @ town, cone end Mate)
B, OuURPene OF ExrsginaneR
@. sare oF czamination
~
+
seep LT UAARNNN FE
oneune1008)
PRIVACY ACT MATERIAL REMOVED
7. eax
G. ance
.
O. Perec veaes sovenmarnT senvict
WILTART
42. DATE OF gINTH
:
15. PLAce OF GinTH
14. MABE, RELATIONSHIP, AND ADDRESS OF MEXT OF cin
68. ERAMIMING FACILITY OF EXAMINER. AmB ADCRIAS
16, @Tuaa terommation
17, gaTine on SPtciaLTy
'
NOTES.
CLINICAL EVALUATION
(Chaod each item in appropriate cot
LL Hebe ded he fe abe bea
11, @ROARIZATION Warr 5
10. setrcr
Civinian
umn: enter “NE'' if not evaluated )
anno.
Tee ia Tes capacrry (Tate)
(Describe every
oerent
|
abnormality in detail.
QAGT SIX BOoWtne
Enter
|
pertinent item number
bef
Conttinue in diem 73 and ves eddional aheeots if receesary sreesech
MA
10, mGae, PACE, M@ECK. Ame Brace
20, sinuses
al. movth amp reroat
22. cans—ermenas Got,4wtomelet ey,
23. seuas (Pevferahen)
24. CvCe—Oememas Sos uses.Sa oon orn
26. opwrnaLwoscoric
26. purrs (Reuskty end reackon)
27. OCULAR weTiLery Lopmeted
cereal aome
28. cunes ane cuert (Etnbeds brenda)
28. neanr (TAruel, ales, rhythm, evunds)
30. vascuuan erste (Varisevines, ate)
Items 0 thru bh? not exmined.
St. appowin ane viscens (Ineleds hernia)
32. amuse amp e@tcTue ;
arp eer
33. empocniae STITER
34. @-u tvstes
38. UrPce COTRESTIES =ewomen ot
Morn
37. Lowen exrecarice
Form, oy eee
ae
3B. SPINE, OTNEA MuUsCULOBEdLEtTaL
38. ISEMTIFYING BOOT MARKS, BOARS. TATIONS
40. Brin LyMPMaATICS
43. MEUROLOSIC (Rpwliti-den ame onde Gm PR
41. PETCHIATAIC LSpenty emp peresnedicy deviation)
43, pawic (Pemoles only) (Check how dons)
CD vacsenr i) RECTAL
{Continue in ttem 73)
44. ecmtar (Place epproprade symbols abou or below number af upper and lower taath, reepactioaly.)
i
m
n
-
=
"
4
5
4
T
a
8
16
"
%
"a
14
iT
16
x
i
rs
2
=
son
nu
m
fl
®
18
18
17
ACWARES AND ADDITIONAL DENTAL
GLFECTS AND DISLABES
aa ar
|i
t
se eines ar one gaa
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6
-_
f-~Neareatorebls teath
ie
(6X Fy—Fised bridge, breckats to
seedude ghuimonds
X~—Mranng iaath
YT —Replaced by dover
LABORATORT FINDINGS
43. vaewalvars
oa. SPECIFDG Beaver
8. aleve
€.
46. cwest n-may (Place, date, Aim sumber and reruil)
B. MICROECOPIC
susan
47. ganoLoe: (Spec/y tert used and rerutf)
a6. tre
49. sicop Tree AnD an
FacToR
BO. otmge tists
Bissett yas eed eo
BEST AVANap) « Copy
;
i
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PRIVACY ACT MATERIAL REMOVED