Agency: FBI
Originator: FBI
From: KC
Document date: 7/5/74
Document type: PAPER, TEXTUAL DOCUMENT

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Released under the John F. Kennedy Assassination Records Collection Act 01 1992 (44 USC 21UT Hote) .

DATE: 11-14-2017

JFK Assassination System

Identification Form

Date:

5/27/201

Agency Information

AGENCY: FBI

RECORD NUMBER: 124-10134-10473

RECORD SERIES: HQ

AGENCY FILE NUMBER :

67-494012-196

Document Information

ORIGINATOR: FBI

FROM: KC

TO:

TITLE:

DATE: 07/05/1974

PAGES:

4

SUBJECTS :

JAMES P. HOSTY JR.

DOCUMENT TYPE: PAPER, TEXTUAL DOCUMENT

CLASSIFICATION: Unclassified

RESTRICTIONS: 3

CURRENT STATUS : Redact

DATE OF LAST REVIEW: 08/31/1998

OPENING CRITERIA: INDEFINITE

COMMENTS: MED RPT, INC FD-300

v9.1

DocId: 32285197

25

Page 1

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## Page 2

, DarIela di Lort188017

General Services Administration

Trengenty Comm. on Medical Record:

KUC. 101€11.809-

LAST NAME- FIRST NAME- MIDDLE NAME

HOSTY

JAMES

PATRICK

4. HOME ADDRESS (Number, street O1 RFD, city or lown, state and ZIP Code

3064.W.5/07

_ REPORT OF MEDICAL EXAMINA.ON

2. GRADE AND COMPONENT OR POSITION

CIVILIAN

5. PURPOSE OF EXAMINATION

ANNUAL

SHAWNEE MISSION, HE

66205

7. SEX

8. RACE

9, TOTAL YEARS GOVERNMENT SERVICE

MALE

WHITE

MiLITARY

CIVILIAN 22

10. AGENCY

FBI

11. ORGANIZATION UNIT

12. DATE OF BIRTH

13. PLACE OF BIRTH

28 AUG 24

CHICAGO, ILL

TANET

some an It 4

4972

EXAMINING FACKITY OR EXAMINER. AND ADDRESS

16. OTHER INFORMATION

Hospital, Ristora-denour (ARCS)

17. RATING OR SPECIALTY OL GOD, MU

62030

TIME IN THIS CAPACITY (Total)

3. IDENTIFICATION NO.

354-16-1873

6. DATE OF EXAMINATION

5JUL 74.

LAST SIX MONTHS

NOR-

MAL.

CLINICAL EVALUATION

chock enter in enteriano ed

ABNOR-

umni enter

it not evaluated.)

MAL

18. HEAD, FACE. NECK. AND SCALP

19. NOSE

20.

SiNUSES

21. MOUTH AND THROAT

22. EARS- GENERAL

(Int. di ext. canale) (Auditory

acuity under items 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-

menta, nuslagmus)

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 (Hemorrhoida,

fistular)

(Prostate, V/ indicated)

33: ENDOCRINE SYSTEM

34. G-U SYSTEM

35. UPPER EXTREMITIES (strenoth, range of

motion)

36.

FEET

37: LOWER EXTREMITIES.(Excepl feel)

Strength, range of motion)

38. SPINE, OTHER MUSCULOSKELETAL

39.

IDENTIFYING BODY MARKS. SCARS, TATTOOS

NOTES.

comment.

Enter portinent item

numbor'beforo.ech

it

REC-140

FIELDSURE

37. 497012•176

lumbered

Se a gee 31 1974

3en

Brathunk

PosteRIon ShoutER

Digital Reetal Norma!

41. NEUROLOGIC (Equilibrium tests under item i2)

42. PSYCHIATRIC (Speci/vant personality deviation)

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

VAGINAL

• RECTAL

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

$2 31 38 Restruble

teeth

32

Non-

o restorable

leth

1 30

Missing

reeth

Replaced

dentures

(Continue in item 73)

Fixed

Partial

dentures

R

REMARKS AND ADDITIONAL DENTAL

DEFECTS AND DISEASES

Exam type 3

ClassI

LABORATORY FINDINGS.

15. URINALYSIS: A. SPECIFIC GRAVITY ), 02-2

B. ALBUMIN

. MICROSCOPH

V.el

C. SUGAR

47. SEROLOGY (Specify test used and regult)

RPR-Ned

AUG 5

48. EKG

Normal

1974

49. BLOOD TYPE AND RH

FACTOR

O. Pos

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

74-6138 NSA

50. OTHER TESTS

Hit 4U%

134

00-16 ров

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Released under the John F. Kennedy Assassination Records Collection Act of 199361 USe

2107 Hote).

DATE: 11-14-2017

-10475

- t.

MEASUREMENTS AND OTHER FINDINGS

51. HEIGHT

52. WEIGHT

53: COLOR HAIR

54. COLOR EYES

55. BUILD:

56. TEMPERATURE

73

•2.08

SLENDER

MEDIUM X HEAVY

OBESE

57.

BLOOD PRESSURE (Arm at heart level)"

58. 4

PULSE (Arm at heart level)

SITTING

srs./15

SYS.

SYS.

A. SITTING

B. AFTER EXERCISE C. 2 MIN. AFTER

TD. RECUMBENT TE.

AFTER STANDING

RECUM-

STANDING

3 MIN.

DIAS. 50

BENT

DIAS.

(8 min.)

DIAS.

60

59

DISTANT VISION

60.

REFRACTION

61.

• NEAR VISION

RIGHT 20/20

CORR. TO 20/

BY

LEFT 20/ 220

CORR. TO 20/

BY

Wait glasse

CX

22//00

CORR. TO 2614.0

BY

CX

22/100 CORR. TO 28/50

BY

62. HETEROPHORIA (Specify distance)

ES°

EX°

R. H.

L. H.

PRISM DIV.

PRISM CONV.

PC

PD

CT

63.

ACCOMMODATION

64. COLOR VISION (Test used and result)

65. DEPTH PERCEPTION

UNCORRECTED

(Tegt used and score)

RIGHT

LEFT

CORRECTED "t:"

66. FIELD OF VISION

67. NIGHT VISION (Test used and score)

68. RED LENS TEST

69. INTRAOCULAR TENSION

wormial

70. 4

'HEARING

71.

KUP MOLES AUDIOMETER

ANSF

72.

PSYCHOLOGICAL AND PSYCHOMOTOR

(Tests used and acore,

RIGHT WV

/15 SV

/15

250

500

1000

300K

04

881

4000

8000

LEFT WV

/15 SV

/15

10

LEFT

15.10

40

.45

8,3%.

65,65|651

73. NOTES (Continzied) AND SIGNIFICANT OR INTERVAL HISTORY

High as Frequeny Hearing losd Both Sails Ive ns

R,

worn glasses for 3 years

EXAMINEE

GENIES FAMILY.HY.

C F

DIABETES/PSYCHOSIS

USE

OF

CON'ACT LESSES/DRIOS.

HY OF

MOTION

SICKNESSI

DISTURBANCES OF CONSCIOUS

7A. SUMMARY OF DEFECTS AND DIAGNOSES (Lial diagnoses win item number A NiT

MEDTCAL TUROTCAL AX

61: QUA OU: UNConcted Eye appointment suggested

71. Hugh Friging Waring loss Bilateral!

75. RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

76.

A. PHYSICAL PROFILE

E:.•

77. EXAMINEE (Check)

A. IS IS QUALIFIED FOR

B. O 15 NOT QUALIFIED FOR

wWD

(ANNuA!)

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

B. PHYSICAL CATEGORY

79. TYPED OR PRINTED NAME OF PHYSICIAN

Lark DistelhorsT Capt

MC FMO

80. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

SIGNATURE

Obios

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

SIGNATURE

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

SIGNATURE

NUMBER OF AT.

TACHED SHEETS

IGNO: 1971 446-644/15

DocId: 32285197 Page 3

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