Pict
MEASUREMENTS AND OTHER FisOunss
Ot. woeHT
82. weient
B23. COLOR main
B4, Co.On gvas
8b. bvn5,
SE. rewrcbatues
CO ecemsre OF wcows
87.
BLOOD Paresuat (dew at hawt level)
a
aivtime
a8.
evs.
| pias.
|
a.
kecue.
Fh BENT
eva.
$6.
c.
rranoine
(3 men.)
bias.
DISTANT vision
eve,
pias.
$0.
Conese
—wuan (Arte at dened Level)
A. SITTING
|
OC oasaer
®. arrte Gxamcut
REFRACTION
{c. 8 min. artee
BD. MECUMGENT
1,
0. AFTER svanping
a etn
wlan Vision
RIGHT 20/
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e
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or
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er
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ox
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62. WeTEROPHORIA (Specviy dratence)
gs?
63.
ax®
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ACCOMMODATION
10
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PRIBE HIV.
Patan Comy.
er
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GE. Chem
OrPTA PERCErTION
£5
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Ce
wuconatcres
Lar
Commsctan
$6. FEL OF Vialon
70.
Lm.
64. coLon vision (Jest used and revull)
87, wrewr vision (Test used and score)
Ft.
WEARING
RIGHT Wy
fib sv
fis
LEFT wy
6 sv
fis
8. RED cams Test
AUDION ETEA
280
00
a56
1000
#32
RIGHT
1084
2000
#048
OS. intasocuLAa Tension
72. (Fone
PEYCHOLOBICAL
cal AND PETCHOMD
;
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TOR
pooo
BOE
gone
4000
eeoo
O145
aoe
fet
=
ur
73. moves (Contmuad) and SiGmiFICANT OR INTERVAL HISTORY
Using bete-cgauma survey meter MI-5, background reading 203~.06 mr/hr,No Radioactive
contamination found,
(Use additional sheats if agoensary)
74, SuUMARYT OF DEFICTS AnD BiagwosES (sal duagnoces with nem Rumbers)
7H. AECOMMENDATIONS—=FURTHER BPECIALIOT EXaminations imbicatic (Specify)
76,
A. PMYBICAL PROFILE
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L
”
t
2
77, cuaminet (Check),
4. Dis ovaivien rom
6.
18 WOT QUALIFIED FoR
G. PHYSICAL CATESORY
78. IF NOT QUALIFIED, LIST GISQUALIFTING DEFECTS OY (VER Mumace
a
7%. TYPED OF PRINTED MAME OF PHYSIC\AN
a Lt Col,
OO. TYPED OR PAINTED NAME OF PHYSICLAN
«
USaF
s Me
e
c
£
SOMATYAL
as
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siomaTURE
“Ol. TVOED OF PRINTED Kame OF DENTIST OR PHTaician Undhosia which)
Sianaryae
OZ. TPC OR PRINTED NAME OF REVIEWING OFFICER OM APPROVING AUTHORITY
BIGNATURE
NUMBER OF atTACHEO SHEETS
«
GOVEAN MENT PRINTING OFFICE, 1087 D-~asneeE
*
*-