Beeedard Fore
(Rev, Jume 1086)
PRIVACY AGT MATERIAL REMOVED
ATIO,
aEPORT
L. LAST MAE INT MAE wIDOLE mane
2. @aaDE 266 ComPoment Of POSITION
2. DeeTIFICaTION ho
4 nome appnrte (Number, aivest or BF D, oily or town, sone and Btate)
$, PuRPORE OF GLAMjNATION
G. BATE OF Examination
7. arr
.
#, TOTAL TEAR® SovenmmewT service |
6.
12. BATE OF BieTH
1a.
24 Juni SA
1t, O@@anIZATION UNIT
(4. MAME. QELATIONSHIP, aD ADDERS OF BEXT OF gin
18. PLacd OF grETH
U8, GRAiming PACrrr Of CLAM (NER, AMD AODREST
.
46. OTMER INFORMATION
rime tn Tie Caractry (Teal)
U7, mating Om BPECIALTY
NOTES. (Describe every abnormality an detail
CLINICAL EVALUATION
Hebe bab
aagucr
ervtcien
wmiviyary
(Check each stem in epproprate cok
umn: enter ''NE' if not evaluated)
somment.
Apion.
wa
Laer BI BoNTRE
J
Enter pertinent item number before each
Continue tn item 71 end use additrona! sheets if necessary
10. MEAB, PACE, MECH, amd cae
18. aour
QO. simutce
HM,
WOuUTH ANE THROAT
22.
LA
tans—eencaa, 2SA teed
ms Fo end Th;
23.
paves (Parforethon)
24. CyCe—mOT ORAL Goatusesse “as ae are
2 + OPHTHAL MOSCOFIC
a
» Pubiis {Bqwality end reacten)
27. OCULAR WoTIL my
(A dimewthed por elle! deren
ern swnlagmes)
20. Lumes ane corset (Jmchads brenads)
2. weamy {Thewasi, visa, rhythm, ewunda)
30. vancucaa svitee (Varicnnie, af.)
Items 7 thru 2 not « murined
31, abDOWEN ane Viacona (Tachads barwig)
32. anus AnD mecTum (momohenis,Semeloe)
33, cwooching srevcm
34. Sy Ovsvem
(Sir vapth. rane
36. UPPER EXvacwiTiC’s gogoe:
36
“
rer
37. cowen extecarrits Gomme, of mentee
a8. seit. GTMER MUSCULOSEELETAL
38. 18CHTIFYinG BOOT Manes. BCARE . TaTToo1
ao. OEIm L¥wPwaticg
41. MEUROCLOS IC (Hewitetem tm water daw MP
PEYCMIATRIC Ulmerfy eng per mensliy dowlenens
a
Peaved (Pomales only) (Check how dons)
“
42.
CD vasimae 0 aterar
{Continus in ftem IX)
46. ockra, (Place appropriads symbols adoes of below number of wpper and lowe loath, reepecthoaly |
O— Reaatorabls ientA
(4X 0)— Fined bridge, brackets lo
T—Munng eath
{—Nemesetoredle leath
a
é “4
"
Pd
2
n
2
YYY —Replaced by dewneres
4
MEWARED
BIPCCTA
AND
ADOITIOMSL
Amo GISTARTS
srclude abuts
L
4
8
?
a
*
10
W
12
iw
14
1B
18
2
a
ss
26
-
3
@.
OM
zx
1
va
W7oOF
\
Ug
T
LABORATORY FINDINGS
435. URIMaLyeis
O@
46. cunet a-aar (Pioce, date, Alem number and rerud)
oA. SPECI” emavety
aLeumis
BD.
wiCmoscorIC
C. Suéar
47. aarcloey (Specty ten! weed ond rerull
48. tee
48. Bigoo TYPE AWD Ow
Factor
$0. orwta Tests
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED
DEMTAL