PRIVACY ACT MATERIAL REMOVED
Standard Ferm
(Rev. Jupe 10545)
. REPORT OF MEDICAL EXAMINATIO.
1. GA8T WhFiRe HALE mae
Bb. SADE AND COMPOR ERT BE POSITION
3. seearinication Wo
4. mower apoetss (AM umber, ses @ RF D. ody or town, sone ond Eanis)
B. PURPOSE OF BAAMINATION
@. DATE OF EXAMINATIOR’
Coe pnt, ke Joh eae
ve
7. 6tx
MiLivagy
t2. bate OF BIaTH
Tt. @@eamization yarr
26 Jul 58
civiLide
13. PLact OF BleTH
1d, mAME, RELATION EMIP, ARD ADDRECSE OF REIT oF Eile
16. OTHER IMFOGMATION
tied am tis cabacery (Teal)
17. maTine OM BPECLALTY
CLINICAL EVALUATION
bab ba be bf bbe be ba be el
a wee te gat
10. seract
$8. SZAMINING FACILITY OF EEAGINER, ANG ABONCSE
noa.
HpRABaer
O. ToT FEARS GOVERNMENT SEAVICE |”
®. Bact
(Check each item in appropriate cob
urn: enter “NE"" if not evaluated }
_|
AbNOa.
Last #1E womtns
NOTES. (Describe every abnormality in detail Gnter pertinent item numbe: before each
eomment. Continue in tem 73 and use additional sheets if necessery.)
WAL
b@. MEAD, FACE. NECK. and BCALP
23. SOUTH awe TeRoat
22. vans—ecarea, OOaL eee el,
230
omuas (Perforation)
2a. crea—arntna, [eeeseesend relyetinen
25. OrntmaLMoscoric
Zé. puriva (Bqwadity ond reachon)
27. OCULAR BOTILITY ges wrawrwes)
ZO. Lunes ane cues Uinelude breasts)
28. waaat (Thrust, wae. rAytin, sownds)
30. vascucan svitcw (Verwenha, ac }
31, aepomre ane viscess (Include hernia)
Items T thru 2 not exzanined
32, anus ame eecto (emer,foie)
35. mMpocaint svatew
34. @-u STSTES
38. unpre crvacernics ce. came of
36. ren
37, Lowen cevmcmrters (freerfee oy eee
agi tar
30. $PimE. OTHER WEBCULONEaLaTaAL
20. 1OTSTIFViNG BODT WARES, BCART. TATTOCE
40, BEin yrmPmarics
41. MEUSOLOGIT Chemie Omnte cmuier doe PR
42. PAYCMIATRIC Lieeeity ome pw mete deredtere!
49. pruvic (Females only) (Check how done)
(Continue in item 73)
O vasimae OD arecta
44. cinta, (Place appreprats qypmbels abo or below number of wpper and Lower teatA, rerpectheay |
aMS
ADDITIONAL
DLA ECTS amb Gis CASES
DIMTAL
tnd we ebutmends
9
10
"
12
13
14
6
te
™
za
2
nm
x
1%
it)
7
439ar
~~
e
a
YT —Repiscad by dentures
2
| mtwanes
(8X H—Fused bevdge. brackets to
X—Missing loath
~
-
cy
4ra-23
O— Rasioradls: tenth
f—Nonrestovabls toatl
LABORATORY FINDINGS
Se Fuk
45. UarwaLeaie-.
46. curst a-mar (Pioce, date, Alm number and recut,
oa. BOECIFIC GmaWITY
@. ALBUM
G
micmoscoric
€. TUeaR
47. stmo.ogy (Spensy test weed and rerudt)
40. ore
49. SL00D TYPE AND an
facTon
$0. oTHEA TESTS
BEST AVAILABLE COPY
PRIVACY ACT MATERIAL REMOVED