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MEASUREMENTS ANO OTHER FINDINGS
BS. COLOR mae
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(Uee addons! sheats i! macsssory)
74. SUMMARY OF OEFECTS AND O1seHobES (Laat dsagmoees with em numbers)
78. RECOMMENCATIONN—FURTULE BPECIALIOT EiAmiMATIONS ImoicaTECD (ipectty)
76.
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76. UF OT QUALIFIED, LIST GISGUACIFYING OEFECTS BY ITEM RUWOER
a
7D. TYPED OR PRINTED NAME OF PRYBICIAN
00. TYPED OF PAINTED MAME OF PHYSICiAm
DISMATURE
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BIGNATURE
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CARL L, HANSEN, Lt Col,USAF ,MC,-f3
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REVIEWING OFFICER OR APPROVING AUTHORITY
NUMBER OF
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Su. 8. GOVERNMENT PRINTING OFFICE: [807 Cannas
BEST AYVAILA Lz COPY
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