eT } ‘id “* JRT OF PHYSICAL EXAMINATIC PIMENT: AS AF OFFICER" A=¥('S)... = dg) AWS “Dats et vxamination S-B-8B ‘Place of examination. Er Civtlien Rank Byes: Pupils (size, shape, reaction to light and distance, ete.) Distant vision Rt. Bars: Hearing Rt. Watch Lt, Wateh 120 Whispered voice -/20 Whispered voice Spoken voico______/15! Spoken -voiee ss 40" Binaural, Mark mining teeth br X whether a Sloe bane 3a ‘Moots dantal requirements Dentures General build and appearance ‘Temperature —. Height Weight. Recent gain or loss, amount and cause. Skin, hair, and glands —_____ Neck (abnormalities, thyroid gland, trachea, larynx) ‘Spine and extremities (bones, joints, muscles, fect)NAVAL X-ray facilities not available. Ro! ‘Thorax (size, shape, movement, rib cage, mediastinum) Respiratory system, bronchi, lungs, pleura, ete. Cardio-vascular system. Heart (note all signs of cardiae involvement) Blood pressure: Before, $152. : Te a Sa Rar Ia After exercise ‘Three minutes after g Condition of arteries, Character of pulse fiill_and reeular ~ Condition of veins ‘normal Hemortholds — Incoordination (gait, speech) —_ ankle, elbow) -... normal. Romberg Reflexes, superficial ..nozmal. Serological tests (when required) — z ‘Amnormal psyche (neurasthenia, psychasthenia, depression, instability, worries) Number of courses. ‘Typhoid ronan { Date of last course ——- Smallpox vaccination Reaction . Remarks on abnormalities not otherwise noted or suflciently described above DONE. Is the individual fit to perform active duty at sea or on foreign service? (If not, state limit of duty) MEMPERS| STATUTORY BOARD. ‘OF MEDICAL EXAMINERS JSEHUCTIONS: De dei iy aie ‘rginal a Bona tad om oy ‘ee See perceron, raery Soret Basie eth "Sa denen4 Zs 2 MARKS, SCARS, ETC. war 20°62 Y | se re eo [eS ‘quently in blac ink, with dave, ‘Tobscompldaly mado up by medial efter at time ofelistment, exten of ealotmeat, veealstneat, evolient, sopolntmst, eae, of Te Date and nasure of any waiver, and defects not noted above (Wadertht nderweihe, daoetive vison, ee) None eee nation. (Signatur ‘Termination by reason of ‘Gromoten, easton, etpran of elicaak, pyia days o) AH physical defects, howover slight