PRIVACY ACT MATERIAL REMOVED
Staederd Ferm @
ion
& noud apeanis ‘(Nembe, aires or EDD, lly or town, owns ond Sate)
7. a2
6. mact
.
$. TOTAL TEARE GOVERNMENT SERVICE
minrrany
12, Bate oF gata
£. GQAGE 487 COMPORTET OA PORTION
2. WENTIFICATION AO.
G. PuRvest of ELAuination
6. BATE OF BLABINATION
10. aermcT
26 dul 58
12, @@CARIZATION BnIT
J civiviam
128, Puce OF BIRTH
14. MAME. DELATIONNNIF, AMD ABONESO OF BEXT OF gin
OS. CAAMINING FACIL TFT OF Exawingn. ame AdeREDE
$4. erneh tnreewation
nae ie rae caracery (Tete)
17, mating @n SPECLALTT
CLINICAL EVALUATION
LEE RE EEL L ERP
oo
Stara) po SPMat PE fp eeINI? AT Oy cs
REPO
0. an) mam e—FlkeT Bam d—mIDeLE RauE
mF
ae
ORCAS Qyot ep Sea4 pecPatae
a
(Rev. June 1956}
{Check each item in appropriate oof
umn, enter “'NE'' if not evaluated }
LAST SIL WORTKS
al
NOTES. (Describe every abnormality in detail, Enter pertinent item number bes,
eoinment. Continus in item 73 and wee additional sheete if ti oCnnee fF.) ore each
songs.
Way
FO. mEAB, Pate, WECE. Aub Ocarce
MOUTH AND TaROAT
22.
Rant—ernena: Ot4oeree eel,
23. saues (Perforation)
z4.
€vES—-SEnEaal guae"usest) eae
OPHTHAL WOSCOPIC
purities (Zeuahy and resstion)
a7 +
OCULAR MOTILITY ae ~eapeons)
» bunds ane curst (Jtehode brescdts)
uaaet (Thrusl, ties, rigthm, sounds)
. WAGEULAR ovETEM { Fariscesias, afc.)
Items 71 thru lb? not exomined
31, apoowte aap viscera (7nelnds harwia)
. ANUS ANG AECTUM [Aromatetme?
35. Ewbocarae syitee
ev SYSTEM
. wrree Extageetigs (Bee. ree of
vrry
47. vowte crveceritsel wymemes
GPimE. OTMEA MuUbCULOBRELETAL
IDEMTIFYIRE BODY MARES. SCARS. TATIONS
46.
SEIN LYMPHATICS
HEVROLOGCIC (Reathinten teem onder tome PR
+ PRYCMIATEIC (Semily sey pereemedion dowledion)
4 » Paivic (Females oly) (Check how dons)
D vasemer 0 acerar
(Continue in ttem 75)
44. pants, (Place approprists eymbels above or below wumier af upper and lowe ieath, rerpechedy.)
—Rasterabls taath
J — Mianng teath
(8X f—Fizad Widgs,
{—Newresterable teath
R
é
1
, =z
2
on
3
PIT —Replaced by denture
4
pa
6
s
T
nope
8
|
.
43. UmemaLysis
e
els
-
10
"W
op
2
pon
aD]
GMs Es AND ADDITIONAL DENTAL
brackets te
DEFECTS amd Biscasan
snclude ebutemands
"4
Pn
§
L
er
TT
T
LABORATORY FINDINGS
46. cues? x-aar (Piace, dete, Ale number and rerud)
A BPECORIC ahaviry
@. ALBUMIN
@. MH AOC OP
GC. sUEAR
47. precios, (Spar/y baat weed and rerult)
ag. tre
40. BLOOD TYPE AnD au
Factor
SO. ormte tests.
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED
ws