PRIVACY ACT MATERIAL REMOVED Standard Ferm (Rev. Jupe 10545) . REPORT OF MEDICAL EXAMINATIO. 1. GA8T WhFiRe HALE mae Bb. SADE AND COMPOR ERT BE POSITION 3. seearinication Wo 4. mower apoetss (AM umber, ses @ RF D. ody or town, sone ond Eanis) B. PURPOSE OF BAAMINATION @. DATE OF EXAMINATIOR’ Coe pnt, ke Joh eae ve 7. 6tx MiLivagy t2. bate OF BIaTH Tt. @@eamization yarr 26 Jul 58 civiLide 13. PLact OF BleTH 1d, mAME, RELATION EMIP, ARD ADDRECSE OF REIT oF Eile 16. OTHER IMFOGMATION tied am tis cabacery (Teal) 17. maTine OM BPECLALTY CLINICAL EVALUATION bab ba be bf bbe be ba be el a wee te gat 10. seract $8. SZAMINING FACILITY OF EEAGINER, ANG ABONCSE noa. HpRABaer O. ToT FEARS GOVERNMENT SEAVICE |” ®. Bact (Check each item in appropriate cob urn: enter “NE"" if not evaluated } _| AbNOa. Last #1E womtns NOTES. (Describe every abnormality in detail Gnter pertinent item numbe: before each eomment. Continue in tem 73 and use additional sheets if necessery.) WAL b@. MEAD, FACE. NECK. and BCALP 23. SOUTH awe TeRoat 22. vans—ecarea, OOaL eee el, 230 omuas (Perforation) 2a. crea—arntna, [eeeseesend relyetinen 25. OrntmaLMoscoric Zé. puriva (Bqwadity ond reachon) 27. OCULAR BOTILITY ges wrawrwes) ZO. Lunes ane cues Uinelude breasts) 28. waaat (Thrust, wae. rAytin, sownds) 30. vascucan svitcw (Verwenha, ac } 31, aepomre ane viscess (Include hernia) Items T thru 2 not exzanined 32, anus ame eecto (emer,foie) 35. mMpocaint svatew 34. @-u STSTES 38. unpre crvacernics ce. came of 36. ren 37, Lowen cevmcmrters (freerfee oy eee agi tar 30. $PimE. OTHER WEBCULONEaLaTaAL 20. 1OTSTIFViNG BODT WARES, BCART. TATTOCE 40, BEin yrmPmarics 41. MEUSOLOGIT Chemie Omnte cmuier doe PR 42. PAYCMIATRIC Lieeeity ome pw mete deredtere! 49. pruvic (Females only) (Check how done) (Continue in item 73) O vasimae OD arecta 44. cinta, (Place appreprats qypmbels abo or below number of wpper and Lower teatA, rerpectheay | aMS ADDITIONAL DLA ECTS amb Gis CASES DIMTAL tnd we ebutmends 9 10 " 12 13 14 6 te ™ za 2 nm x 1% it) 7 439ar ~~ e a YT —Repiscad by dentures 2 | mtwanes (8X H—Fused bevdge. brackets to X—Missing loath ~ - cy 4ra-23 O— Rasioradls: tenth f—Nonrestovabls toatl LABORATORY FINDINGS Se Fuk 45. UarwaLeaie-. 46. curst a-mar (Pioce, date, Alm number and recut, oa. BOECIFIC GmaWITY @. ALBUM G micmoscoric €. TUeaR 47. stmo.ogy (Spensy test weed and rerudt) 40. ore 49. SL00D TYPE AND an facTon $0. oTHEA TESTS BEST AVAILABLE COPY PRIVACY ACT MATERIAL REMOVED