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Standard Form #8
Retised April 1964
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General Services Administration
Intceragenvy Comm on Mednal Records
1, LAST NAME—FIRST NAME—MIDOLE NAME
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4. HOME ADORESS (Number, atreet or RFD, city
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CLINICAL EVALUATION
(Check each femin appropriate column, enter ''
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11. ORGAMIZATION UNIT
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16. OTHER INFORMATION
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14. NAME, RELATIONSHIP, AND ADORESS OF NEXT OF (IN
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15, EXAMS) BlOGlontexlinkh WdoLOmeRCtLOn
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710. AGENCY
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6. DATE OF EXAMINATION
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§. TOTAL YEARS GOVERNMENT SERVICE
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CIVILIAN
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3. IDENTIFICATION NO.
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13, PLACE OF BIRTH
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8. RACE
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12, DATE OF BIATH
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| 2. GRADE AND COMPONENT OR POSITION
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REPORT OF MEDICAL EXAMINATION
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LAST SIX MONTHS
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Enter pertinent item number before each
ontinue in rtem 7J and use addtional sheets if necessary )
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20 SINUSES
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21. MOUTH AND THROAT
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GENERAL acuity wader lems 70 and 273
23. DAUMS (Perforation)
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(Wermel acuip and refraction
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EVES
~GEMERAL wader tfeme 7? 60 and G7)
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OPHTHAL MOSCOPIC
26. PUPILS (Aiguality and reaction)
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28 LUNGS AMO CHEST (include breasts)
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29. HEART (Taras, #ire,rAgttm, sounds)
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30. VASCULAR SYSTEM (\ericosities. ete )
PRIVACY ACT MATERIAL REMOVED
31. ABOOMEN AND VISCERA (/nelide Aermia}
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(Hemorrderds
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ANUS AND RECTUM (Prestate of indicated)
23) ENCOCRINE SYSTEM
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44. G-U SYSTEM
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37. LOWER EXTREMITIES |een
A range of motion)
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MEUROLOGIC (Kemiiorium frete wader item 72)
43. PELVIC
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REMARKS AND ADDITIONAL DENTAL
DEFECTS ANO DISEASES
44, DENTAL (Place appropriate symbols, shown in examples, above or below mumber of upper and lower teeth.)
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45, URINALYSIS:
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A SPECIFIC GRAVITY
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47. SEROLOGY (Specify test weed
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LABORATORY FINDINGS
AG. CHEST X RAY (Place, dole, log nubider Ent pantry SS f3
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US Aray Health Clinic
BD MICROSCOPIC
46. EXG
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49, BLOOD TYPE AND AH
FACTOR
30, OTHER TESTS
Ft McEherson, GA 30330 .
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