MEASUREMENTS AND OTHER FINDINGS
87.
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pcos parsoune (Aru at heurt level)
aA
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oe.
e
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FrAnDINe
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DISTANT VIBION
86. Teergnaruns
84. euico:
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83. Conon main
62. whem
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& OrTTne
6. AFTER EXERCICE
@EFRACTION
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irs
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62. weTeROPnona (Spen/y dratance)
ase
63 .
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Prism BIY.
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e
( Tet weed end result)
rm
65. tfew
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ro
i UNCORRECTED
Lert
comatereo
66. FIELD OF VIRION
76. .
=
v viston
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1.
MEARING
mieut wr
sin av
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Lerr wy
f18 8¥
fie
O60. QED Lang Test
AUDIOM ITER
200
454
too
$18
rooa
1084
2000
8048
SD. wrraaccuLar Tension
72. PRYCHOLOGICAL AND PaYCHOMOT.
{Testa weed end seers)
woroe
sooo
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acco
ded
econo
8144
epeo
S108
RIGMT
fn
73. moras (Comhawed) And StOMIFICANT O8 INTERVAL HISTORY
In 39 PD radiations: ele.5 mr/rr, not above background
(Use additonal shests 1f necessary)
74, QveuarY OF DEFECTS AND DiaenosES (Laat diagnose: wilh em members)
7H. RECOMMENDATIONS——FURTHEA SPECIALIST EXAMINATIONS LMDICATED (Speevy)
Ts,
A. PeYSICAL PROFILE
’
u
L
*
t
s
Y7, examinee (Check)
a. Oe euativico ror
o. Das mor quaimee ror
Bb. PHYSICAL CATEGORY
70. 0F MOT GUALIFICD. LIST OFQUALIFYING DEFECT OY (TEM NUMRER
76. TYPED Of PRINTED BAME OF PHYSICIAN
G0. TYPED OR PatnTEO Wamg
OF PwYSICIAN
a
ats.
82
SIGMATURE
OF
e
OWATURE
SIGNATURE
PRINTED MAME
e
sienatond
Oi, TYPED OF PRINTED WAM OF DENTIST O8 PHYBICIAN Uinchonie which)
Prep ON
.
REVITWING OFFICER OF APPROVING AUTHORITY
WUMBEA OF ATs
TACMED SHEETS
J.B. GOVERNMENT PRINTING GFFICE, 1057 O-asalag