PRIVACY ACT MATERIAL REMOVED
Ttanderd Ferm
(Rev. June 1956)
REPORT OF MED!
ATIO.
1. LAST WAM Fiasy MATIDOLE Bae
2. GaADL AMO COMPORMENT ON POSITION
3. (OEM TIFICATION WO
4. wOME aooaces (A mie, etree o AF OT, cy oF town, sone and Slots)
B. PLAPOSL OF ELAMINATION
6. DATE OF EXaninarion
7. OEX
@.
mace
\*. TOTAL YEARS SOVERMAENT
12. ATE oF gimrtH
$3. euace oF giata”
4,
1B. CLAM IBING PACILITY O@ ENAMIRETA, AND ADOATSN
ACLATIOND WIP.
AMG
AODACEE OF
CLINICAL EVALUATION
NOTES.
agmon,
“a
MEET
OF
f1n
INFORMATION
Tima 1 Tee Caracrry (Talal)
(Check gach stem in epprapriate cor
umn_enter "NE of not evaluated |
Zo&
MAME,
14. OTHER
17, GATING Of BPECIALTY
i be bab Lae bab eb
V1. OMG ANITATION Warr
10. agtncy
FEOVICE
j coviteam
[wrivane
AGT BLE MONTHS
Enter pertinent item number before each
(Describe every abnormalhty in deta
oomment. Continue in item 73 and une additional sheets sf Neceseary_)
1B. MEAD, Pace, MER. AMD BcaLP
1p. noon
21. MOUTH 4nB YHROAT
iar @ at, teens Uhh
+ RAROSCENENAL Way wade tires feend 7)
23. peums (Peeferaheon)
4 Fumeal
24, CVES—SOmERa, Gee
teeth ona
ae daeiteca
24. oPmtmarMascore
24. eurics (Bowalty end renchon)
27. o¢uLal woTiiity Sonnetpen
20 Lunes amp corer (Znctude breasts)
28. ncaet (TAruai, mse, rhytam, sounds)
30. vascuLan aretea (Fenomnhe, atc.)
31, aepoman ame vincona (Imctuds hernia)
Item 1 thro &? not examined
32. amps ane etctoe ime w iatereanth
4 - ERBOCHIOL SyeTce
‘
34. @u erste
33. veraa cxrecmitiga Seth renee a
46. ree
37. cowee axrmerries Srop ee
30. artnet. Otmea wuntuLosaeietay
3
IDTRTIFTING BOOT MANES, SCHAAS. TATTOOS
40. Shim Lrmenatic®
G1, MEUROLOOIC (Rptkievem teste wader them oF
42. PETCMIATRIC (open ty cme peremhahty domahons
43. pauvic (Females only) (Check Aow done)
|
os
Vy waits C) Reta)
(Continue in item 73)
DENtaL (Pace eppeopreaus mmbols aboeg or below number of upper and lace loath, ret peach bely.}
O— Rasorwhle tenth
(6kO—Pisad beudga, beach ata be
wcities Gbuaterends
X += Af vesing teath
«moO
-
o
4
~
a~
x»
-
Co)
-
-
a
YYY — Replaced by dentures
es
a
|
160
Wi
no
2
12
13
4
16
16
19
18
Wy
AE MEATS AND 09,1 fom ROnTAs
DEFECTS ano DiStAsE
4aner
440
LABONATORY FINDINGS
03. VOImALYSIS,
@
46. Crest xemay (Place, date, Aim number and resuil)
A BeRCIFIC emavity
aLOumin
B. mickoscgrit
©. svesae
47, Sno. Oey (Spal) leet weed and rerull)
48. tue
48. GLooo TYPE AND aM
Facto
30, OYNke TEEs
' BEST AVAILABLE COPY