~ PRIVACY ACT MATERIAL REMOVED
REPORT ©
‘
.
1. LART MAB E——F1esT mam —wIbOLE wae
2. OROCe and CoMPOHENT OM POEITION
3. WENTIFICATION a0
4 NOME AbDacea (Number, aren or KF UL, aly oF own, pens ond Sinise}
$. PURPOEE OF ELAM BGTION
@. eave OF Ckamination
7. oa3
10. agtacr
.
6. mate
9. TeTAL
VEARE GOVEQNMENT BEAVICE 7
wrLivaar
12. QATE OF GuTtH
16, Otula imroamarion
TISE IM Tole capacery (Taal)
CLINICAL EVALUATION
NOTES
(Check sach item an appropriate oof
umn: enter “NE if nat evaliyvaeted )
foz
=.
26 Jol 58
14. MAME, RELATIONSHIP, AMD APORESE OF MEXT OF Kin
Q7. aavina O88 @PaciALTY
Dt Pt bd bt be be be
V1. gaeasization var
{ Civigials
13, *LACS OF BETH
U8. CRAMINEHE FACILITY O8 ELAMINER. AND ADDRESS
apnor-
(Describe every abnormality in detail
eomment.
LAST 861 MoWrHe
Enter pertinent stem number before gach
Contunue in item 7) and use additional sheeta Un wosesary .)
wa
18. MEAD, Fach, SECE. amo BcaLP
1B. most
it, woutm asp THROAT
oem samales La wd:
U2. EARS—OCNTAAL (her.
Clin@ease
sit PendTHs
23. oaues (Perforanen)
24, EVCR—wOENCRAL Gearuserdeeo cardi
al al akoal a
ZB. OPHTHALwoECOPIC
28. purica (Bowed ty end ranches)
27. ocuran woticrry maretad pered
26. Lunes amo cutest Cimolede bregate)
29. meant (Thewal, visa, rhption, sounds)
30. vascucar svetce ( Varwnnhes, atc.)
Items 1 thrn 12 not exmmined
31. aspomwan ane viectrs (Jeahuds Aernia}
32. anus ame ecctum (foot, Sons?
2S. repocaiee erevew
34. @-u pretie
romps of
35. vePer ENTACUITIES (Birsngts,
Sonos,
a. ei
97. Lowen exvece ries ef os ce
36. SPINE. OfmEm MUSCVLOREELEtaL
30. DENTICVING BODY MAREE, SCARS. TATTOOS
40. GKIn Lomemarticg
41. MEUROLOSIC Likeetaneem meets omier item Tr
42. OSTOMIATIIC (Smemyy omy permet demenen!
43. waivic (Pomales only) (CAack kow dons)
OO vasimac () nner
{(Continus in irem TS)
aa. otnta, (Place oppreprate eymoads bow: or below number of upper and lower bests, respectively }
X—M vwaaing lesth
(¢X H—Pwaed bevdor, brackas te
e
|
26
ACw4AES BGO AODITIONAL BEMTAY
BCrFECTS amo GiRCARES
smcluds abutments
s
10
WwW
12
13
té
6
14
Fa]
a
Rm
a
~
"”
18
1?
AR
~
a
on
YX — Replaced by dentures
~
i)
~~
-
O— Ranorable tecth
f—Newsstorabls lnats
ArO-7
FER. GHNR
tie
Crandesd Fem &
t
. dame 1046)
LABORATORY Minoince
O35. uarma lysis.
8
46 crest remas (Place, date, Aim number and reryil
SPECIFIC @RaWwITY
|
Bo
micagscoric
e. fuean
47. staoLoes (Specr/y dest weed ond resuil)
48. cue
42. OLOOD TYPE 4hO aH
a
SO. OTHEN TESTE
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED