PRIVACY ACT MATERIAL REMOVED Sasda Form & (Rev. June 1946) NATIC.. RE 1. LAST MAM e—eRET Memes IBLE Waue mums muemgee ee sireat or BP Di, sity oF tron, sone ond Binis) . oan @. mace O. TOTAL THARE GOVERABENT BERVICE mLrtaay 12. BATE OF BretTK 2. SRAGE AND COMFORT RT ON POSITION 3. sbeertiptcation wo B. PURPOSE OF Ehasin tion G. DAaTR OF ExaminatiON U3. PLACE GF biRTH time In Tas capacery (Tate!) CLINICAL EVALUATION hoa. (Check sech item in appropriate col umn: anter NE" if not evaluated ) apna. LAFT Sik woWTHS NOTES. (Describe every abnormality in datas. Enter pertinent item number before wach aomment, Continue in item 73 and use additional ahetta if necessary was 14. Whab. Pach. mica. ano scape 18. BOSE 20. simusis 21. BOUTH AND THROAT iw oepels (A aah sory 22. Eame—semtnay OS, farms Po ae Ty 2). taues (Perforanen) 24 CVLOOENT RAL ClouseabRoarer 2b. oputmarwoscoric 24. Purics (Equality and reaction) 27. ecucap woviery Ametteied pevelial erm 28. Lunes amp CHity7 (Include breasts) 2D. mean (Thewat, mea, rhydhn, spends) 3 » VASCULAR OvSTEM (Varcomiian, alc.) o some a od od wh vd ot od vt wh ot mb ok ob oe wal i2 aw 18. OTHER imFoamaTION 17. Rating Ge BeEcIALTY x | 26 Fut 14, MAME, GELATIONSNIP, ARO A0OREES OF BTXT OF gin 1B, CLAWINING FACILITY Of ELADINTA. Awd ADDATOS p 11. OREANITATION YaRrr 10. agency CoVOLIAN Bi. Appowsn ano viscees (Include hernia) fms, nn 3 - ANUS AND RECTUM Items 1) thru 12 not exaxined Aovedes) een 33. cuooceiat grate . 3 § @u britte . * (Serewgth, came as » URPCR EETRE MITES ihe 30. ron 37. LOWES COTREMITIES Sorteromps of mettond x, 26. BPISC, GTMEA MUSCULOBEES ETA, , Jf. IDENTIFVING BOOy WARES, SCARE, TATTOOS 40. Stim LrmPnatics . 41. MEUNSLOGIC Chpatitewen inate ede dam OF 42. POTCHIATRIC Uipemsy ome perermabiy demain? 43. pauvic (Female only) (Check how done) DO vaca, ( neetar (Continue in fram TH) aa. StNTAL (Place apprepeai: symbols ahoer or below umber af upper end Loewe Lasth, rerpactheely.) ~ sp sey nore ele NN won DR 18 a 8 te nw 1@ 18 WV OLFCevs amo BibCARtS 4aane .- ht » MCw Ahad Ano BOD Toma, DENTAL IH X Si —Fised bridges, raskas to teclide abutments X—Mvwsine toath WIT —Replaced by dentures + + LADOMATORT FINDINGS 450 UMIWALYSIS @ a6. cheat memay (Place, date, Alm number and rerull: oa. SPECIFIC SRAVITT @iBumin 6. micmoscoric €. syugaa 47, atno.oey (Specly tent used and rerudl) 48. one 48. BLOOD Tree amb An Factor $0. OTHER TEETS BEST AVAILABLE COPY PRIVACY ACT MATERIAL REMOVED