REPORT
(Rev. June 1986)
1. LAST HAM E—FLEET MAME GICSLE BAU
£. GRADE Amd COmPONEAT OM POSITION
be
.
3. iDErtiricatran mo
.
& WOME ADDRESS (A wmee, arent & BP OD, ty oF town, sone end Binis)
7, eax
PRIVACY ACT MATERIAL REMOVED
Ga.
Standard Form 08
@. aacr
{s. TOTAL TEAHE SOVERMMENT Stavice
j Meustaay
(2. BATE oF GIRTH
8. PURPOSE OF CxANpuation
10. aenacr
@. Batt OF Chamination
TT. OmgamiraTion UNIT
Civivias
I}. eLaAch @F gIRtH
14. MAME, GEUATIONE MIP, AND AODREGH OF NETT OF Gin
€
£
1B. CXAmImIMe FACILITY OA EXAMINER, AND ABDAESO
2
Hf>
17, mateme Om SPECIALTY
:
Time te rwis Capacity (Teal)
lea
a
te the she dee de a be i feS=
oe
1
FE
ie
ate te ake
f
18. ormge isfoamation
LAMY SI BowTns
tf
seEHR FS2 RSCMLSEELC
E
‘;
.
NOTES. (Describe every abnormality in detail.
ume, enter "NE" if not svaiuated }
VB, MEAG, FACE, MOCK, ane scale
Enter
pertinent (tem
be
wa
ts. nose
20. simuens
21. WOuTH ANS Trost
22. Camper ran, Uooeoreo heel,
23. eaues (Parforahon)
26. Cree—enwenadwaar wer oo wuceare
25. GPHnTNALBOECOPIC
26. Purice (Reality ond reaction)
27. ecuLas motiirry Amerie
sree! moe
28. Lunes ano cucey Cinaluds breasts)
Th. meant (Tarwel, oss, rhptin, sounds)
20. vascucen ovetce (Verweenhe, a.)
81, aepowcn ane veacrns {Jmotads Morne)
Items 311 thro 12 not examined
32. emus ame acctye (PooSo
33. tudoteing 8veTEe
34. ou tyre
.
.
368. vPege astacmitegs cee. Comoe af
36. rer
37. towra exraturries bom
wel.
mange af muantien)
30. BPINE. OTHER BUsCULOBRELETAL
39. IDEWTIPVINS DOSY MARES. Beane. TATTO’S
40. Skim Lrmewatics
61. BEUROLOOIC CBewintee wee ede dee
42, PRTC MIAT RIC Lipa ty one permmehey domamen)
i
.
43. otivic (Females only) (Check how dome)
i
4
i
i
.
0) vesiwar CO) aterar
(Continue in stem 73)
44. canvas (Place epproprat: yebals atows or below number of upper end lower lasts, psspectesy }
O— Rastorahle tenth
i
X—M aang tenth
{— NWenremorabls oath
;
R
YT — Replaced by dentures
i
$
2
3.
4
5
6
|
4 rn
&®
2
He
FP
{
1
?
t
Uebel eth,
@
Ai SuUbin
c.
tusaa
s
wm | eu
450
(6X M—Pired brdgr, brackas te
sadudr ecutmenis
DETECT AND DISEARED
L
10
"1
2
13
14
16
6
2
wm Mm
wm
1
1h
oF
.
BEMAGES OND ADDITIOWAL BEWTAL
E
7T
LABORATOAT FIMDiInGt
og
oBPECIFIC @maviTy
47, atmo.oe: (Specly tent wand and remedy
46. curat a-aas (Place date. film number and reruil)
Oo
micmascoric
46. exe
49. BL0OD TYPE awd fm
Factors
36. ofwan Thats
|
{
|
f
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED