PRIVACY ACT MATERIAL REMOVED Ttanderd Ferm (Rev. June 1956) REPORT OF MED! ATIO. 1. LAST WAM Fiasy MATIDOLE Bae 2. GaADL AMO COMPORMENT ON POSITION 3. (OEM TIFICATION WO 4. wOME aooaces (A mie, etree o AF OT, cy oF town, sone and Slots) B. PLAPOSL OF ELAMINATION 6. DATE OF EXaninarion 7. OEX @. mace \*. TOTAL YEARS SOVERMAENT 12. ATE oF gimrtH $3. euace oF giata” 4, 1B. CLAM IBING PACILITY O@ ENAMIRETA, AND ADOATSN ACLATIOND WIP. AMG AODACEE OF CLINICAL EVALUATION NOTES. agmon, “a MEET OF f1n INFORMATION Tima 1 Tee Caracrry (Talal) (Check gach stem in epprapriate cor umn_enter "NE of not evaluated | Zo& MAME, 14. OTHER 17, GATING Of BPECIALTY i be bab Lae bab eb V1. OMG ANITATION Warr 10. agtncy FEOVICE j coviteam [wrivane AGT BLE MONTHS Enter pertinent item number before each (Describe every abnormalhty in deta oomment. Continue in item 73 and une additional sheets sf Neceseary_) 1B. MEAD, Pace, MER. AMD BcaLP 1p. noon 21. MOUTH 4nB YHROAT iar @ at, teens Uhh + RAROSCENENAL Way wade tires feend 7) 23. peums (Peeferaheon) 4 Fumeal 24, CVES—SOmERa, Gee teeth ona ae daeiteca 24. oPmtmarMascore 24. eurics (Bowalty end renchon) 27. o¢uLal woTiiity Sonnetpen 20 Lunes amp corer (Znctude breasts) 28. ncaet (TAruai, mse, rhytam, sounds) 30. vascuLan aretea (Fenomnhe, atc.) 31, aepoman ame vincona (Imctuds hernia) Item 1 thro &? not examined 32. amps ane etctoe ime w iatereanth 4 - ERBOCHIOL SyeTce ‘ 34. @u erste 33. veraa cxrecmitiga Seth renee a 46. ree 37. cowee axrmerries Srop ee 30. artnet. Otmea wuntuLosaeietay 3 IDTRTIFTING BOOT MANES, SCHAAS. TATTOOS 40. Shim Lrmenatic® G1, MEUROLOOIC (Rptkievem teste wader them oF 42. PETCMIATRIC (open ty cme peremhahty domahons 43. pauvic (Females only) (Check Aow done) | os Vy waits C) Reta) (Continue in item 73) DENtaL (Pace eppeopreaus mmbols aboeg or below number of upper and lace loath, ret peach bely.} O— Rasorwhle tenth (6kO—Pisad beudga, beach ata be wcities Gbuaterends X += Af vesing teath «moO - o 4 ~ a~ x» - Co) - - a YYY — Replaced by dentures es a | 160 Wi no 2 12 13 4 16 16 19 18 Wy AE MEATS AND 09,1 fom ROnTAs DEFECTS ano DiStAsE 4aner 440 LABONATORY FINDINGS 03. VOImALYSIS, @ 46. Crest xemay (Place, date, Aim number and resuil) A BeRCIFIC emavity aLOumin B. mickoscgrit ©. svesae 47, Sno. Oey (Spal) leet weed and rerull) 48. tue 48. GLooo TYPE AND aM Facto 30, OYNke TEEs ' BEST AVAILABLE COPY