◆ SpookStack

Standard bor 8s Reavis Apr oes haces ocaget ws AE ueiey Tie cae. a Maat yt, BE SEE fed meta 1, LAST wa me EVA) AME MITTIE AME MATTE eit © ROME BDDRISS iN aimter gee! or APD, fp Ot Pye a, © . . Rab Pg jee Pa P, Sex an 12. DATE OF giIRTH @ Race a tt og PG IN. PLact OF BEATE aw” i. Bae TY pe Peed C Fee 13. EXAMINING FACHITY Of Exarinin ano ADDRESS ATE GS nry ~ tat TF, RATING OM SPECIALTY HeIpR ech enc A item it appropiate col: wi siren enter ONE at nog evaluated fj AB. HEAD. FACT WRECK AND ScacP ee tS west q {20 sisuses | i Sn nn Sentence te ee 21. MOUTH AND THROAT t i t es 5 Pet ext anata oA diiiey 4 a2 #5 — a H fans Gent ab wetatty wader iivows MY amd Daa } P23, CAUMS CP eeforaticn: | RS OPATHALMOScCoRIC , : RE. PLIES CRguatitvand reatn ny) . 7 Mdeaor aged waren’ mace | 2h OCULAR MOTHLITY Rents ytingmas CRIA tonite ree te i 4 LUNGS: AND CHEST (fai tud? terenty: : ; ee rt 1 MF) MERRT (Taras, suze, Taya, sounds) ! a — a eae acini | BP hASCULAR SYSTEM CM urate sete i ——— a —— _ 2 YE, ABOGMEN Bao VISTED A Uimclode bern) | ! ag ey tte ENDOCRINE SYSTEM ‘ ee ee G-U SYSTEM - LRPER Eat REITs ¢ noe nee ag tetagth eunyge at - Pat rere 1 27. Lowe ep atagest LS ecsth cangesimetian | : ae Sime randeetemteas | BM. SPINE, OTHER MUSCULOS*ELETAL : L349 IDENTIFYING BODY MARKS SCARS, TATTOOS byt | 140 SKIN. LymPnatics { : fe mee me PAY, NEURQLOGIC cPewstitricin teats uniter stem 24s | 43. PEC (Kemaies ‘galyi 1 Caeck Raw doar) Chyacimar Clrecra, TE PSYCHIATRIC ix ectyane wer eomadity dorkadiaat | #4. DENTAL (Plsie appropriate spatial, wbusew am amples, abure or below aumber of apper and lower tooth 3 © i . : iit Beaten itil: ° any f ui Ravel, a rer Foredewriale , ; a mo haeth ; R é u 2 3 é 5 é 7 a ; % a x» so] a it s eee &. ALSUM MER « REPORT OF MEDICAL EXAMINATION fo hy , Merand FH Coder $ = 1 2 13 14 1s Gb-~117 1 2. IENTIFICA TION WO. ee TU OC tv} & DATE OF Examination 2, GRADE AND COMPONENT GR POSITION § PURPOSE OF EXAMINATION A & 10. AGEncy ly ay 2s U1, GRGAMILATION UNIT chek 14. MAME, RELATIONSHIP, AND ADDRESS OF NEXT OF xin uv Ss 16. OTHER INFORMATION TIME 1 THIS CAPACITY (Tota) LAST BX MONTHS, (Describe avery abtormaliry in derail Enres pechinent rem mumbar before each comment. Continue initem 77 and use odds tional sheets i Neesesary 3 $a. NOTES b7¢ per Array (Continue ia item 73) REMAHRS AND ADDITIONAL DENTAL DEFECTS AND GNSEASES a CTTI,. ‘ce Replaced Fixed . song Me Rtaers oe y orateres 3 #2 2 x GABORATORY FueeENES @, BLOOD TYPE AND RH FACTOR