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# REPORT OF MEDICAL HISTORYTHIS INFORMATION IS FOR OFFICIAL USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS1. LAST NAME-FIRST NAE-MIAmron, Irong5. PLACE OF EXAMINATION6. DATE OF EXAMINATION7/4/644. HOME ADDRESS: No STREET, CITY OR TOWN, COUNTY AND STATE260 Marshall Ct, Long Branch, NJ10 AGENCY11. ORGANIZATION UNIT7. SEX8. RACE9. TOTAL YEARS GOVERNMENT SERVICEMale light12. DATE OF BIRTH13. PLACE OF BIRTHDec 4, 1917Brooklyn, NY14. NAME, RELATIONSHIP, AND ADDRESS OF NEXT OF KINBella Amron, Wife260 Marshall Ct, Long Branch, NJ15. EXAMINING FACULTY OR EXAMINER, AND ADDRESS:1248 Norwood Ave.16. OTHER INFORMATIONHarold Cochel, M.D. Oakhurst, New Jersey17. STATEMENT OF EXAMINEE'S PRESENT HEALTH - (Follow by description of past history, of complaint or injury)I am in excellent health18. FAMILY HISTORYnegative19. HAS ANY BLOOD RELATIVE PRESENT IN FAMILY HISTORY, SUCH AS:    TUBERCULOSIS, DIABETES, CANCER, HEART DISEASE, ETCRELATIONAGESTATE OF HEALTHIF DEAD, CAUSE OF DEATHYESNO (Check each item)Father75goodMother66goodWife37goodSon40good* HAD SYPHILIS* HAD DIABETES* HAD CANCER* HAD KIDNEY TROUBLE* HAD HEART TROUBLE* HAD STOMACH TROUBLE* HAD RHEUMATISM ALLERGY* HAD ASTHMA HAY FEVER,  HIVES* HAD EPILEPSY* COMMITTED SUICIDE* BEEN INSANESistersChildren7good9good16good20. HAVE YOU EVER HAD OR HAVE YOU NOW, (Place date in () of each item)YESNO (Check each item)YESNO (Check each item)YESNO (Check each item)YESNO (Check each item)* SCARLET FEVER, ERYSIPELAS* GOITER* TUMOR, GROWTH CYST CANCER* TRACHOMA OR OTHER EYE DISEASE* DYPHTHERIA* MUMPS* RUPTURE* FOOT TROUBLE* RHEUMATIC FEVER* WHOOPING COUGH* APPENDICITIS* NEPHRITIS* SWOLLEN OR PAINFUL JOINTS* FREQUENT OR SEVERE HEADACHE* SHORTNESS OF BREATH* PILES OR RECTAL DISEASE* PARALYSIS OR WEAKNESS* DIZZINESS OR FAINTING SPELLS* PAIN OR PRESSURE IN CHEST* FREQUENT OR PAINFUL URINATION* EPILEPSY OR FITS* EYE TROUBLE* EAR, NOSE, OR THROAT TROUBLE* CHRONIC COUGH* KIDNEY STONE OR BLOOD IN URINE* CAR, TRAIN, SEA OR AIR SICKNESS* RUNNING EARS* DIFFICULTY OR POUNDING HEART* SUGAR OR ALBUMIN IN URINE* FREQUENT TROUBLE SLEEPING* CHRONIC OR FREQUENT COLDS* HIGH OR LOW BLOOD PRESSURE* VENEREAL DISEASE* FREQUENT OR EXCESSIVE NIGHTMARES* SEVERE TOOTH OR GUM TROUBLE* CRAMPS IN FOUR LEGS* RECENT GAIN OR LOSS OF WEIGHT* DEPRESSION OR EXCESSIVE WORRY* SINUSITIS* STOMACH, LIVER, OR INTESTINAL TROUBLE* ARTHRITIS OR RHEUMATISM* LOSS OF MEMORY OR AMNESIA* JAUNDICE* GALL BLADDER TROUBLE OR GALL STONES* BOILS, CARBUNCLES, OR OTHER SUPPURATION* BED WETTING* ALLERGY* DIFFICULTY IN SWALLOWING* LAMENESS* NERVOUS TROUBLE OF ANY SORT* ASTHMA* BLEEDING GUMS* LOSS OF ARM, LEG, FINGER, OR TOE* ANY DRUG OR NARCOTIC HABIT21. HAVE YOU EVER (Check each item)* HAD HAY FEVER* ATTEMPTED SUICIDE* PAINFUL OR FREQUENT BOWEL MOVEMENTS* EXCESSIVE DREAMING HABIT* WORN ARTIFICIAL EYE* BEEN IN A SLEEP WALKER* HEMORRHOIDAL TENDENCIES* WORN HEARING AIDS* STUTTERED OR STAMMERED* COUGHED UP BLOOD* WORN A BRACE OR BACK SUPPORT* BEEN TREATED FOR NERVOUS OR  MINTAL ILLNESS22. FEMALES ONLY - HAVE YOU EVER -* COMPLETE THE FOLLOWING:* BEEN PREGNANTAGE AT ONSET OF MENSTRUATION* HAD A VAGINAL DISCHARGEINTERVAL BETWEEN PERIODS* BEEN TREATED FOR A FEMALE DISORDERDURATION OF PERIODS* HAD PAINFUL MENSTRUATIONDATE OF LAST PERIOD* HAD IRREGULAR MENSTRUATIONQUANTITY23. HOW MANY TIMES HAVE YOU HAD THE    SAME JOB IN THE24. WHAT IS THE LONGEST PERIOD YOU    HAVE HELD ANY OF THESE JOBS?PAST THREE YEARS?MONTHS31225. WHAT IS YOUR USUAL OCCUPATION?26. AGE YOU (Check one)Technical Translator