(toa-10175-10162 . ie ‘ . e . { : i ‘ : H tio. @antant Forms ~ - — oo x | faevitocrts 8s "5 : Re ry wet ee a ect REPORT OF MEDICAL HISTORY ; Ctacv eam A- 3 Tees FORMATION MG FOR VITAL HSE ONLY AND WELL OCT AE BELEASED TH PRAETACHIZED PERLOES : i t é i ad a MM Livgrre | OE - - - tg “TOR PLACE OF erm oT" RANE, BRLATERDET, Bm ALORES aS . “ | ME PPD gee BH 1 7- EB : 2. STATEMENT OF EXAMGGE S PRESLEY CAL Te & OUR WORDS. ¢ Fasee by descrigtwon ef past user, ff completes epmtes ~ WKAR PO VEE AL =~ £ REL Pings - Me COLMPLAIIVIZ a ee tae 1 BB. HAS enV BO RELATION (Parent, bratker, % vauny wsccer ton cheep easter, OMe} LATO ABE STATE OF HEALTS : iF CLAD, CASE OF DEATH oe (Check exch item); OELATYINIS) | fareae tw ~— : fy aifruwaA bog = + Bad TURERCULOSS : 437 R BOOT eee 5 | _ . 1 ive Gor 1 MAD SYPHILIS tos * ‘ | i ¢ AD OLABETES 4 Orig, i { om | WAD CANCER } te | MAGS RDAEY TRL ‘ : feng GAD HEART TROUBLE i & | MAD STOMACH TROUBLE tg : Ro AS RHEL ATISH f Artbritae ,! . : STRER GAY TECER oO: ests dot BAD EPILEPSY ( Fits! H . : o> ; COMMITTED SUICIDE i or” BEEN UNGANE - © TiMOR, GAGATH, CYST. CARCER oo RPE PESTS {ey ARTS. SWOLLEN OR PAIL, SCANTS ejastma 7 PRES Of FECT AL DEERE [ o] PARALYSIS (Jae. mmfontde) —s i | ee | ere emer [eRe RE eee mee | vi CHRORIG CouSH ese I Vf FPEQANT TIOLALE SLEEPING - : Pe Sues renee | i" mus FREQUENT 02 TOREETING wegHTEARES : eeereror o> YENEPEAL CASEASE ee . HH epamaraar | FTlaararus | reoremonasa ean | [laseremarenren | oe [TA sowocine a nrsmai nea [_, > ene om on creamy | | [Remon Tecmo! ak ANY ORG OF BARCOTIC HAGIT ~ | Excebsree DRRKING HABIT \ te Pager a cmt “TRR™ LER o8 OOH | MOSOSEX VAL TEADERCES 4 Hi t é (Cheek each item) | e+} sevens Too7H 08 Gut TROUBLE “] ss [arom 2h, Wade YoU EVER (Check week stem) 2 PUMALES OMLY AMAUE POL EVER ——_B COMPLETE THe FOLLORING ; , WF worn GLasses [serra sme 1. Skin pReoRAnt |_| AGE at ORSeT OF MENSTRUATION sro ewe “|= sco vine uae RRS SS] emnonorimmtemen | [maitmornnae a if sruriEnco OR STAMWERED | » [ cOvGNED UP RKO + AD PRR, WORST ILE TOS |__| oar oF tase cnioo “ys j [&"t poss a BRACE Of BACK SLFEDET i #aG IREGLL AR wERsTe.ATIOS Quantity [Jucmen {Joscawe LJ ecuaw 2% mopar wary res Wart FOR pad we Tie TA BHAT €S Tee Loess” PERIOS TOU 2h, MOAT & YOUR Gad CCCI? 2% ARE VOU (Check one} OaSt Verte PEARS? MELD ANY OF THESE aces? - ‘ + f MONTHS bye Bet ees BaP (Bpvaeer asmces:  (] vary weoesen | on ast Seer wmen ene) oe nce s Poss ww an
* ‘ . : 4 4 4 . } d 4 i ves | wo! CHECK CACK (TC VES OR 4G EVERY CTEM CHECOED FES WLST OF FLALY CAPLARED @ GLARE SPACE ON Bxtert , ‘ - ‘ a 7. wave YOU Bilin URAGLE TO HOLD A 508 BECA.SE CF. af : &. SEGITIVITY TOCHEVICALS DUST SUNLIGHT ETE. | 4 8 BL INABILITY TO PERFORM CLATALE WITS 3 ow |G. IMABAITY TO ASS WE CERTAM POSITIONS . a © OTHER MEDICA, REASONS [Uf yen, give raamoaial - | 2 Gave VOU EVER WORKED WITH RADIOACTHE SUB. : ¥ STANCE? “3 ” 3S. DID YOU HAVE OUTIOATY wit SCHOML SOS : OR TEACHERS? (if poo, gra det asia} . ‘ al BR RAVE YOu EVER BEEN REF! ED EMPLOY MENT BEALE oF PGR WELTY Ul yes, state reason and 4:98 . otmade: ° got WH. HAVE YOU EVER BEES DENIED LIFE INSURARCET (if yoa, state reason and give detastess 32. HAVE YOU WAD Of HAVE YOU BEEN ADVISED "s HAVE, i uw ANY OPERATIONS? Uf pes, descerbe esd are age at which oceurred) 33. WAVE YOU CvtA BEES A PATIENT (como--tred oF wolumtary) U6 & WEMTAL HOSFITAL OP LANATOR- ” uM? (7f yes, apecaty when, where, a~ 7, and ma ene of doctor, and comprete adaress of fowegeee os M4, UAVE YOU EVER HAD ANY KLNESS OR MIUTe CTWER FRAN TerUSE ALREASY MOTEL? <4/ Fee, specety when, where, aad give desacia} 3S. HAVE YOU COMSLLTED OR BEEM TREATES &* Cun PHYSICIANS REALERS. OF OTPER PRAT UOMERS WITHER THE PAST 5 YEARS? (lf yea, gre com plete addre. a docter, Avepstad, cluauc, and detasis) peernen M, HAVE YOU TREATED YOURSELF FOR inLAESTE OTHER TrAN MeOR COLES? Cf yes, whack sineneee) 39. HAVE YOU EVER BEEN REXECTED FOR ~WILITARY SERVICE BECAUSE OF PHYSICAL. MENTAL CA OTHER REASONS? Ulf yea, give date and ressos tov rejection) steers teehere ‘3G. HAVE YOU EVER BEEN OSSCHARGED FRO MLITARY SERVICE SECACSE OF PHYSICAL MENTAL SR OTHER we” REASONS? Cif ves, give date, reesca, and type of discharge: whether tanoradle, other than honorable, for un&t nes of ute acueabalssy) 38 HAVE Toe fA FECT ED, ff TERE PERC IAG, HAVE YOU APPLIED FUR OF DO YOU INTEND WS aeeLY Pom PEXSION OF COMPENSATION FOR EXSTiw3 CISASIL- OSy? iif yes, specuy what kind, granted by whom, and what amount, when. wiry) i @CERTUFY THAT I HAVE REWYE@EDS THE FOREGO 6G INFTSWATION SUPPUED GY WE ANS THAT IT KS TRE AND GoetLete To ‘ § AUTHORIZE ANY OF THE DOCTORS OSPITALS CA CCG WENTIONED ABOVE TO Pitta THE GOVERAMERT A ComPLETe F. ‘ OF PROCESSING MY APPLICATION FOR TeIS EMPLOYMENT OR SERVICE Se oF WY Kw TELsPGe OF MY MTOR. RECORD FOR PLAMOdES z fy t i i j ere Fae nee ae PuRae oF PRINTED MAME OF PMYEICIAN Of EXAMINER H i . a [- i . o- secre ve teemeremerenmrone g J | | tore 2 een eee