PRIVACY ACT MATERIAL REMOVED
GQeeaederd Form ©
(Rev. June 1656)
REPORT
EDI
..
1. AGT RADE FIAST MAME OTRO RANT
£. Gmapt Ame ComuPonecet ce Postion
2. IDERTIFICATION WO.
& wour [Cepansn (A eae, arent or BF D, ally o town, sens ond Btnls)
8. Peuneos: Of Examination
6. DATE OF Cham RATION
¥. ace
10. asnct
@. nace
/e. TOTAL YEAes SOvCRawEWT aeeviCE
meeraae
14. para oF sietH
14. WAGE. BELATIONSHIC. ABD ADORERE OF BETT OF Kin
16, otace imroRnaation
U7. marine @8 aPuciaLty
ae a eae ao ol
—24_Jn}_ 55
| crvinean
V2. PLACE OF B:RTH
U8. CAAmIMIAG FACILITY O8 EXAMINER, AND ADOREDS
he
1), epeamiatios var
Time im vars capacrry (Fetal)
NOTES.
CLINICAL EVALUATION
(CAecd each item in appropriate column; enter NE" if nor eraiusted )
asnoe.
(Describe
every abnormality in detail
Catt 81K meted
Enter
pertinent fiem number
bel
e2nment. Continue in ftem 73 and wee eddnsonal aheots necessary _. onch
wa
10. rae, Fact, MECR, awe ecayP
21, SOUTs AnD THROAT
22. cats—~eemcna USOTLtens SentTh;
23. prums (Parferatwn)
24. evds—erncaas peersmaa
28, oPetTHALMoscoPC
26. eurits (Bemahty and reschen)
27. ecuuan sorirry Sete
al! moe
20. cumes ano const (Jacluds brenets)
20. weanr (Taewet, eins, rAytin, arends}
20. vascucas aretem (Varicenies, atc.)
®
31, apoowcn ane viscraa (imebude hernia)
items 32 thro L2 not exammed
32. AWUS AND RECTUM iRoMt ‘nneind)
.
33. cmpocking svavee
34. &-u OTSTEw
38. Grere extaceyes tore. me of
36. rerr
37. cowce exragmrries Som ay mets
36. SPINE. GTmame MUSCULOSKELETAL
3D. IDENTIFYING BODY MANES. BCARS. TATTOOS
4
- BRIM UVePwATICS
@1, MEUROLOSIC (Kewthimtam tents emder Saou PY
Lod
42. POYCMIATRIC URnamty any puremesiitp devinmem
43, patiwic (Females oly} (Chant how dons}
D vasiwa. CF) ezerac
(Centinus in item 75}
44. ecntay (Place eppropreats eymbols abow or below number of upper and Lower Lasta, rerpecealy.}
(0X M—Fused bridge, bractats to
X—M seins beath
O—Restore: tath
YY —Replaced by denteres
simeteedle Sdnatevee
.
é
*
77
a
7
4
ER
6
a
?
Ree
8
9
16
WwW
12
a
a
|
eB
RB
eee
18
+28 r
fx—Nenrestorable tasth
MCMORES AUD ADBITIOMAL BEMTAL
BCPECTR ARO DISEAGKS
LABORATORY FwpINGS
45. uiimauvac®
©
oa BPtCuRee @RaviTy
steven
46. cucet n-mas (Place, date, Alin number and rerud)
©. mic MOeCOrC
c. susan
47, atmo.ogy (Spanfsy bee! weed and rarull)
40. cue
48. BLOOD TYPE AND an
Factoae
$6. oTWan Tests
ga
rie
hn
ey
.
al 7
Ne EH
Dial at
i
.
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED