PRIVACY ACT MATERIAL REMOVED
Stan dard Farun 06
(Rev. Jupe 1654)
REPO
N10.
1, LAST BAB E—FIRET BAe IDOLE Mame
E. ORAGT AND COMPGHERT Of POSTION
‘
4 some aednace (A umber, strest or BF D, enty of town, sens and Mais)
B. pureost OF Euapination
7, aae
10, astacy
@. aacn
;
{9 ToTal YEARG GovERNUENT srewiCl
{ wiertaay
1E, BATE OF gIatH
Uh, eneamizarioe var
16, OTWEeR (RFORMATION
Tis tw twig Cavacery (Teal)
|
NOTES, (Describe every abnormality in detail,
CLINICAL EVALUATION
(Check each item an
n appropriate col
uma, enter NE"
of 3.5 a
SS PER
14, MAME, BCLATIONSAIP, AND ADDRES OF NEKT OF tN
7. marine Ga SPECIALTY
ae:
6. paTE OF Chawiaation
| civiias
(12. Puact oF mimtH
16. ERAMINING FACILITY Of EXAMINER. ANG ADORESS
if not evaeiuared )
@eommenit.
aancn.
way
Last 01x wowrne
Enter
pertinent tfam numbe.
at.
SOUTH AND TwRoat
cans—metnena, Ceeeeee eT,
eauns (Perforation)
24.
ev Ce—mecm can, Luceoomond rere
28.
DPNTMALMOSC ORE
PuPiLs (Equality end renalion)
27. OCULAR moTiLTr Asmmetetper
edie! mew
26. Lunes amp crest (include breasts)
waant (Thrust, wise, rhythm, sounds)
. wastuian system (Varwecthes, alc }
anUS 6D actus f
Items 1 thru 2 not examined
mote. oy ad ened
. ENDOCRINE SvErTtM
.
. OU SVITEe
a8.
verre extacwitics eons. home of
voc
a7.
t
LOWER EXTREMITIES eee,
oy enon)
SPINE. OTMEO MYSCULONRELET aL
. IDENTIFYING BODY MARES, BCARS. TATTOOS
46,
Baim
LYMPeaATICS
ai - MEUROLOGIC (Ek emaintetee tees ome tome PF
42.
PSYCHIAT MIC Lemmy eat pent iy deere
4}, etivic (Females only) (Check how done)
a VAGINAL
Oo
{Continus in ftem 75)
SECTAL
44. penvar (Pioce approprals symbols adore: or below number of upper and iewer loath, eespectinaly )
X— Musing lesth
4
98
tI
at]
18
Vv
+49
_
~
nw
7
8
_
=
s
8
6
ROP
o
4
ACWANEE BMD ADDITIONAL DEATAL
OCPECTS AND DISEABES
vecids ehutmenls
8
3
oS
oe
Lad
7
%
1
Bird
(6X #—Pired tridor, brack ats le
YOY ~ Replaced by dentures
/— WWonrestorabls laath
@
O— Restorable loath
LADOAATONT FINDINGS
45 UmimALTSIS
A. SPECIFIC GAAVITS
@. ALOYMIN
46. ¢ucsr xemay (Place, dade, Alm number and recud)
Db. MICROSCOPIC
€. SuGar
47, serovocy (Span/y lest wed and rerut)
a8. nes
48. BLooo TYPE amo fu
WaACTOR
fi
Continue sn item 73 and uss addtronal sheeta if necesea aay ore each
WEAR, FACE. @ECK. ANG SCALP
abpowtn ano viscrea (Jmalude hernia)
4ra-z
~~
3. 1eAATIFICaTION HC
.
$6. orwHin TEs
BEST AVAILABLE Copy
PRIVACY ACT MATERIAL REMOVED