Agency: FBI
Originator: FBI
From: KC
Document date: 9/3/76
Document type: PAPER, TEXTUAL DOCUMENT

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Released under the John F. Kennedy Assassination Records Collection Act of 1992 (44 USC 2107 Note).

DATE: 11-14-2017

JFK Assassination System

Identification Form

Date:

5/27/201

Agency Information

AGENCY: FBI

RECORD NUMBER

124-10132-10096

RECORD SERIES :

HQ

AGENCY FILE NUMBER: 67-494012-206

Document Information

ORIGINATOR: FBI

FROM:

KC

TO:

TITLE:

DATE: 09/03/1976

PAGES:

12

SUBJECTS :

JAMES P. HOSTY JR.

DOCUMENT TYPE: PAPER, TEXTUAL DOCUMENT

CLASSIFICATION: Unclassified

RESTRICTIONS:

3

CURRENT STATUS: Redact

DATE OF LAST REVIEW: 09/01/1998

OPENING CRITERIA: INDEFINITE

COMMENTS: MED RPT, INC FD-300

v9.1

DocId: 32284518

Page 1

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Releaset under the John F. Kennedy Assassination Records Collection Act of 1992 (14 USC 2107 Hote).

Pandard Form 8: 2017

Revised?

ol2908

General Pervices Administration

Interagency Comme on Medical Records

FPMR 107-11.809-3

REPORT OF MEDICAL EXAMINATION

2. GRADE AND COMPONENT OR POSITION

3. IDENTIFICATION NO.

1. LAST NÄME -FIRST NAME-MIDDLE NAME

HOSTY

NAMES

7:

3014W

7. SEXi

B: RACE

Westwrol its 66205

9. TOTAL YEARS GOVERNMENT SERVICE

5. PURPOSE OF EXAMINATION •

annual

10. AGENCY

11. ORGANIZATION UNIT

6. DATE OF EXAMINATION

3 11? 7.6

12., DATE OF BIRTH

13. PLACE OF BIRTH

J8auy 24

Chicago Ill

15. EXAMINING FACILITY OR EXAMINER, AND ADDRESS

VA Hopital

КС Мо.

17.-RATING OR SPECIALTY

or' wife

16. OTHER INFORMATION

TIME IN THIS CAPACITY (Total)

LAST SIX MONTHS

CLINICAL EVALUATION -

NOR-:

NOTES.

Don wienever ntinue alienand se addition she ism number boloro each

"Check each item in,

appropriate col-

umn; enter

it not evaluated.)

ABNOR-

MAL

18. HEAD, FACE, NECK. AND SCALP

19. NOSE

20. SINUSES

21.

MOUTH AND THROAT

(Int. d est. canala) (Auditor.

22. EARS- GENERAL acuily under itema 70 and 71)

23. DRUMS (Perforation)

24. EYES-•GENERAL

(Visual acuity and refraction

under items 59, 60 and 67)

25. OPHTHALMOSCOPIC

26. PUPILS (Equality and reaction)

27. OCULAR MOTILITY (Associated parallel move-

ments, nustaomus)

28. LUNGS AND CHEST (Include breasts)

29. HEART (Thrust, size, rhythm, sounds)

30. VASCULAR SYSTEM (Varicosities, etc.)

31. ABDOMEN AND VISCERA (Include hernia)

32. ANUS AND RECTUM (Hemorrhoids, fistular)

(Prostate, if indicaled)

33. ENDOCRINE SYSTEM

34. G-U SYSTEM

35. UPPER EXTREMITIES- (Streroth, range of

motion)

36. FEET

37. LOWEREXTREMITIES, (Except feet)

-atrophio right testicle

no other abnormalities

noted.

Strenath. range of riotion)

38. SPINE, OTHER MUSCULOSKELETAL

39. IDENTIFYING BODY MARKS. SCARS. TATTOOS

40. SKIN. LYMPHATICS

41. NEUROLOGIC (Equilibrium tests under ilem 72)

67- 4940/2-206

REG-1 Bearchec

Numbered

: IL. SEP 21 1976

42. PSYCHIATRIC (Specifuany personalily deviation)

43. PELVIC (Females only) (Check how done)

VAGINAL RECTAL

%.

(Continue in item 73),

14.: DENTAL (Place appropriate symbols, shown in examples, above or below number of upper and lower teeth.)

Non-

teeth

32.

3i 3o restorable

12 3 30 Missin

teeth

32 31 30

Replaced

teeth

Fixed

Pursial

dentures

SAND ASSATIONAL DENTAL

ПАД,

2

31

30

29

28

27

26

25

24

-23

11

22

12

21.

dentures

13

20

14

19

15

18

LABORATORY FINDINGS

45. URINALYSIS: A. SPECIFIC GRAVITY

B. ALBUMIN

C. SUGAR

46. CHEST X-RAY (Place, date, film number and result)

D. MICROSCOPIC

and resull).

48. EKG

49. BLOOD TYPE AND RH

FACTOR

50. OTHER TESTS

88-116

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Released under the John F. Kennedy Assassination Records Collection A 32199 due 2107 mater.

DATE: 11-14-2017

MEASUREMENTS AND OTHER FINDINGS

51. MEGH 7/3"

57.

A.

SITTING

SZ. WEIGHT

-de

BLQOD PRESSÜRE (Arm at heart ledel)

sYs. /10

DIAS: 7/2

53- COLOR HAIR

55. BUILD:

56. TEMPERATURE

SLENDER

MEDIUM

HEAVY

OBESE

59.

RIGHT 20120

LEFT 20/

SYS.

DIAS. 61L

RECUM-

BENT

DISTANT VISION

CORR. TO 20/

CORR. TO 20/

20

62. HETEROPHORIA (Specify distance)

ES°

EX°

STANDING

(3 min.).

sYs.(20

58.

PULSE (Arm at heart level)

A. SITTING

DIAS. 82

- 8 оди.

AFTER EXERCISE C. 2 MIN. AFTER

61.

D. RECUMBENT E.

AFTER STANDING

3 MIN.

NEAR VISION

BY

BY

S.

CX

Cx

442 CORR TO 11/1VBY

R. H.

L. H.

PRISM DIV.

PRISM CONV.

CT

PC

PD

63.

RIGHT...

ACCOMMODATION

LEFT

66. FIELD OF VISION

nornal

70.

HEARING

64. COLOR VISION (Test used and result)

65. DEPTH PERCEPTION

(Test used and score)

Passe

67. NIGHT VISION (Test used and score)

68. RED LENS TEST

UNCORRÉCTED

CORRECTED

69. INTRAOCULAR TENSION

71.

AUDIOMETER

72. PSYCHOLOGICAL AND PSYCHOMOTOR

(Tests used, and score)

RIGHT WV

/15 SV

/15

56

518

1000

1024

2000

2048

3000

4096

6000

3900

RIGHT

LEFT WV

/15 SV

/15

LEFT

73. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY

chrome atrophy right testick

(Use additional sheets if necessary)

74. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

пок

75. RECOMMENDATIONS- FURTHER 'SPECIALIST EXAMINATIONS INDICATED (Specify)

ском

77. EXAMINEE (Cheik).

A. DO IS QUALIFIED FOR

•B. [ 15 NOT QUALIFIED FOR

78. IF NOT QUALIFIED. LIST DISQUALIFYING DEFECTS BY ITEM NUMBER

79. TYPED OR PRINTED NAME OF PHYSICIAN

RIF. STONE, MD.

80. TYPED OR PRINTED NAMÉ OF PHYSICIAN

81. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN!( Indicale which)

82. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY

76.

A. PHYSICAL PROFILE

B. PHYSICAL CATEGORY

SIGNATURE

SIGNATURE

SIGNA

moo

SIGNATURE

DDS

NUMBER OF AT.

TACHED SHEETS

# U. S. GOVERNMENT PRINTING OFFICE: 1969 0-352-273 (49J)

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