(404-10175-10181 , rt 34 RANE, SRATERS Ant AO0PESS OF GLET =F Aue i me. = 5 gut . - . i seagecen toa E> REPORT OF MEDICAL HISTORY LY i TH MOF ORMATION TCR 62) Cte ESE ONLT ORO WL OCS BS GUL EASEh TH wasuTeGREG PERSOME mo oxmeenncerecseanetneteneten et A AE . . LAST MAWES UL” MAME -LLE ha rk 2 BALE ARS Coneo NENT CAR POSIT RAE A icdeiap cate a. : a srenenennennnennenennn . i §. C.uGSE OF Exseuma RON. * j & DATE OF Damnation Lee tM wb a eS GOS: SemccE 1G, DEPART WENT, ASERCY,Cal- SeRVICE ; Ti. ORGANLZAT OM Incr ‘ ‘ f  'Waite are ae me i Gi. STATEMENT OF GRAMMES 9 PRESENT AL Yo m CWH BOERS Fs Faw qiead ni fA Health normal - feel fine - no complaints, Th Pawny wis-car 18 nAS ane BOE RELATION (Poreit, wetter, water, aRe+ L30 bdo ME 8 SVATE OF HAL“ © SEA St AD SYPHILIS 4 , a ee hits x neers "Mother ae ete Kaeere 7 } AD KIONEY TRO 1X AD HEART TROBE : {X —-4aD STOMACH The aL 1X ORME MATION erase i xX? 7.3.8 RARE FTE Me iNott ceescse XC 1 SWORLES Ce PANFLR JORTS a PAA SS ene. indaataey . MUMS PS seowreess oF enzaTH (K FREAeWT om pans smarem Poy | mon ais Kivcowmer | xTawermaiaenodr [x dav intone acer 7 | FREQ. ENT 0 CEVERE VEATACHE ~ SHRORRE COG “X S.GAR C4 ALEC Be “RINE INC} OG2INESS CH FANT BOG SPELLS Es PRLPUTATION £8 2c STING BEART Xmas OVE TRO RE ~ | (RGN GR Low BLoCO PRESSOME | (MOMEOTAL - * LEAR NOSE CR THROAT TROUBLE “%: CRAMPS BH OAR LEGS . scant i acanins mars PREQGENT PRLEGESTION 3g) CHRCAN Ga FREQUENT Cons Xi SEVERE TOOT CA GL TROL BLE | SINUSITIS XM! aay ere a wet YOU OVEN (Check each stact) WD PEWALES RAY A AcE tA. L0ER—~ B COMPLE THE FOLLOW Sages ee nee . * [| worm Grasses yc | atrEweren scion ; RL erica . BCE AT CREST OF MERSTHOATION ee eeseh SEU gana ee ee: es ee en 7 WORN AM AYTE CUAL OFC X | Seah 4 Saker aLAER 4” AS & PAG INAL ORCC | Est, RET WER PROCS — aan sa BORN MARAG AIDS ( teeuss OM {1 SOM reaaTea FoR 4 remeL RTOROKR ' SURATION OF PLROOS i. AG: sivrTteso on stamurers x | GeeD UP mace + RAO Parmer, UERSTRAT OR . TATE S# LAST PERUOG an ne mre me a TS ie ELEM. on peermmemaa & aeer nf hm a ee pasty Kwon a essct ca ascx Surrost! x Se eal + RAD EEG LAR ERR ATION QUACITTT? «cota, jaxcesmee [cacy ccm wanty joss eas TON TRE at? 5 Teoh LONGEST #058100 TOY 3S. Ghat & TOL ns OCC eT ORT 1 Oh 8G CL (Chek ome) aye Tee Vis a3" l woe id Business Ma iazement> Xewe wer! (ur amm t SO GaraP-
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