MEASUREM
$1. werent
62. waent
.
$3. Coron wan
BLOOD Pressuae (drm at haort lead)
a
Ba.
GTHER FINDINGS
$4. aulio.
04. rrepewarues
D suenpee DD mtcwe
87.
artina
AND
B4. COLOR EYER
ars
6.
arcum.
INT
bial fe
ave
|
ee.
C.
OUTANT VIBION
C1 onnse
puis (Ares of haart ional)
a. Sitting
ra STANDING
Bias.
(3 mem)
Clea
B. AFTER ERERCION
C.F Min. AFTER
G. RECUMBENT
#0.
REFRACTION
@1.
uotn.
WEAR ViBIOR
RIGHT 20/
Coen
To gos
CM
5.
or
CORA
to
Lory
Bore
FO g0/
or
4
oa
coAA
TO
ros
L. AFTER Francine
dias.
br
OZ. wevenoenonia (Specnfy demiancs)
as?
£3.
tx*
Rw.
accommobaTION
hiGHT
cient wy
Ley av
PRIsM Biv.
Page CONY.
eT
c
as. perm PEOCEPTION
O7. mien vision (Test wend end score)
60. ato Lies reer
ial
71 .
HEARING
fis ay
wis av
)
*o
wacoanecten
COMMECTED
66. FIELD OF VisION
70 .
ue
04. COLO’ ition (Tew uacd and result)
fue
ne
AUDIOMETER
z50
B56
$09
iz
1000
1024
sooo
9048
OD. cwrkaocuLan TEnaion
72. (Teme
PETCHOLOGICAL
mau AND PEYCHOMOTO
,
R
sooo
S896
ao00
4006
enco
6144
sooo
8168
acer
”
tn
73. moTze (Comhaued) and SIGNIFICANT OF INTERVAL HISTORY
Using bete-gauma survey meter MI-S, background reading .03-.06 ar/hr. No radioactive
contamination found,
(Use additional sheats if necmsery)
T4. GUMMARY OF DEFECTS AND Diagnoses (lsat diagnose wih vem aumiers)
7S. MUCOMMENDATIONO—FURTHER BPECIALIST EXAMINATIONS embICATEO (Specyy)
74.
A, PMYEICAL PROFILE
L
*
77, quamingz (Cheok)
a. © is quatirico ror
eo. Oia wor ovativice ror
@. PHYSICAL CATEGORY
Th. UF MOT QUALIFIED. LIST DISQUALIFYING DEFECTS BY ITEM BUMBEA
FR. TYPED OR PRINTED HABE OF PHYSICIAN
Si@WaTURE
CARL 1, HANSEN, Lt Col, USAFNC =?S
OD. TrPRD OR PRINTED MAME OFPHYSiCiaM
GIGMaATURE
@1, TYPED OF PRINTED WARE OF CENTIET OR PHYSICIAN (I mchonds which)
GIGMATURE
B2. TYPED OA PRINTEO MAME OF WEVIEWING OFFICER OF APPROVING AUTHORITY
| SIGNATURE
NUMBER OF AT
TACHEG SHEETS
»&. GOVERAMENT PRINTING GFFICE: 100) G-—weslne
BEST AVAILABLE Copy