MEASUREMENTS AND OTHER FINDINGS
Ol. aElenT

SL. wiient

$3. COLOa main

G4, CoLom EVES

$8. bule

O86. Tewrcratuas

CD) sicucee Do weae
s7.

biped Pecesuee (drm ot Asari level)

a.
orrrma

|

eva.
clas

SB.

.
aya.
aecunGENT) Dian

wey

ts.

¢.
stanpine
(5 mam.)

eirtant wabron

ave.

Ol wcevy

(2 ooene

euigt (dew ot Aaned level)

A. BIrtine

O. arrae exeeciag

C. oo wim. ArTeR

6/6. Recumnaws

lag.

0.

REPRATTION

st

|. sFTRe granting
amin.

NEAR VieloE

RIGHT 20/

coma. ro 20/

er

s.

o

fONR, To

or

LEFT t0/

come To 80/

oy

s.

ox

come TO

e

62. urtenopnonia (Spernfy dustence)
ree
64.

axe

RH.

ACCOMMODATION
.

Rian?

RiGHT Wy

urn ww

Paige Bry.

Paiba Cony.
fy

~

#4. coLon vision (Text used and rerul)

GB. thas
DEPTH Peacertion
ade

67. misuy vision (Test used and scere)

60. NED LON TEx

Ce

i
|_uncoanecren

)

en

CONNECTED

66. FIELD OF visiON
70.
°

ua.

t
8
onan

71.

fia av

fis

fis ov

416

AUDIOMETER
asec

B5¢

goo

aie

10600

YOLr4

2600

#048

0. WTAAGCULAR Tansion

72. PRYCHOLOGICA, AND PSYCHOMOTOR
(Tents weed and sere)
3000

8406

4000

4006

eoc0

SI4i

eooo

S188

RieHT

“

Lert

73. wores (Conteued) anp BISNIFICANT OM INTERVAL HISTORY

Using Beta-Cauma survey meter MI -5, background reading .03-,06 mr/hr, No radicactive
sonteamination found.

(Wee adduhonal sheats (f necessary)
74. SUMMARY OF DEFECTS AND GiasmosEs (List diagnose: with dam aumbders)

PE. RECOMMENDATIONS—FURTHER SPECIALIOT EXAMIMATIONS INDICATED (Specify)

76.

&. PHYSICAL PROFILE

°

u

L

“

£

a

77, axawinte (Check)
4.0 ts euacivige ron
a. Dts not auacteieo ron

B. PHTBICAL CATESORY

78. UF 8OT QUALIFIED. LIST OISQUALIFTING DEFECTS BY TEM NUMBER
79. TYPED GR PRINTEO RAME OF PHYSICIAN

a

c

r

sienaTuae

CAD LL. Brveey, Tt ColSAFMOPS

* 60. TYPED OF PRINTED MAME OF PHTBICIAN

SIGHATURE

81. TYPES OR PaInTeD MAME GF OEWTIOT OA PHYSICIAN UInchenle which)

SIGMATURE

82. TYPED OR

PlSnaTURE

PRINTED NAME OF

'

REVIEWING OFFICER OR APPROVING AUTHORITY

,

NUMBER OF ATo

TACHEO SWEETS
. 8. GOVERNMENT PRINTING OFFICE.

BEST AVAILASLE SOPY

four Om-asenee

Select target paragraph3