Fares 08 (Rev. Jaume 1056) RE L. .AST Bem C—TIRET BAe Bae BR. ORAS AND COMPOMERT Of POSITION 3. le@emtipcation ao d. HOME abbagsn (A ube, aed @ BPD, nity & tn, cone od Beata) $. PURPOEE OF ELAmiMATIOR mm @. BATS OF EaAMination 7, oan 10, aerncy 6. mace ©. TOTAL FEARE Govenwuterr eeRvicE MtLrramy 12. DATE OF DIATH Sond a “_ 0G. OTHER INFORMATION Time im THis Capacety (Totes) CLINICAL EVALUATION (Caeckt each stem in appropriate. ook umn. enter NE’ if not eval df) 14. wrap, Face, NECK Amb BcaLP copeeeesecleset 2. 14, mONE. RELATIONS OIE, ASE BBOGEAS OF HEKT OF tin 07, @arine om BPECIALTY NOTES ABNOA- LAFT 81x mwoItns (Deecribe every abnormality in detail Unter pertinent item number before each momment. Continues in stem 73 and use additsona! sheets if necessary.) 1B, mont 21, wouTH amd THROAT 22. pane—erngna OUSL ead Th 23. seuss (Perforation) 24. ATER—OCNERAL Gearceede ot oneer 28. oputnatmoscoric 26. eurica (Bqwahity end reachan) 27. ecuiaa serum A ertated Eaole mo 20. Lunes ano crest (Jmehods bremats) 20. meany (Thenst, sie, rhythm, erunds) 30. vascuLam sretéu (Veriostha. ac.) 31, aboowan awe wrectaa (Jneieds harena) Items 11 thro Lf not exmined 32. anus and RECTUM ‘Pree U nands 33. cmoocerma nyatem 34. ®u STsTeM 98. upper axvacwrvies eres. rem of 36. rere 37, Lowes extacumies ior of ntion) 38. petat. otmre mUsCULOaECL ETAL 30. IDENTIFVING BODY MARES, SCARS. TATTOOS 40. grim L¥menarTice 41. WEVRCLOGIC (EewQQetnm ime onde ten OF + WOVE MIATRIC CSpesity omy peemesdlep dovkation he ae 11, O@eanumation war Civilian 08. pace OF GiFTH TB, CRAM INInG FACILITY OR ELAWINER. AND SBDaTES Ere PRIVACY ACT MATERIAL REMCUS: TIC, . PELVIC CPemalee ondy) (Chant how dons} CJ vacrear (0 accra (Continwe in ttem FS) 44, etmta (Pisce approprials qymbols above or below numer of upper end ieee teath, prpectoaly.) — Rastorable lesth T—Minag ieath fueNenrestorehle inath A 4 1 H x T r 1 (0X H—FPiuzed widge, breackas te YYY —Reploced by dente 4 5 ‘ ? a ® a 2 Sed F ei om REWLAED Ant ADBrTiOma, DEMTAL DEFECTS AMD DISTASES teolwds Soules 10 W 12 2 am . 13 14 18 L aber ts 1. roof T LABORATORY FINGemcs 45. UaimaLyaiS- a a. SPECIFIC SEaviTy a.bumin 46. Coeat x-may (Pines, date, Alm numer end rarutt) G. micwoscoric €. tuésa 47. scaovos: (Specn/y tat weed and rerulf) 46. nreé 40 L600 Tret amo an $0, piaae Toms Facton BEST AVAILABLE COPY PRIVACY ACT MATERIAL REMOVED