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REPORT OF PHYSICAL EXAMINATION
(See AR 40-100 and 40-105)
I
che Instructions. Regular Army National Guard. or Officers Reserve Corps: and enrollment in the Reserve Otficers Training Corps. Use typewriter if practicable.
Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant ofticers applicants for Attach appointment plain additional as such in
a
sheets if required.
1. Britton
Ida
(None
(Serial number)
a
(Last name)
(First name)
(Middle initial)
Civilian applicant for appointment
Age
32
Years of service
2
(Grade)
(Organization and arm or service)
(Nearest birthday)
(Whole number only)
3. Nature of examination 1 Appointment
Component of Army
2
Army of U.S.
4. Typhoid vaccination. No. series completed
3
Last series
Nevember
,19 40
M
5. Date of last smallpox vaccination November 1935 Type of
reaction
Vaccinia
6. Other vaccination or immunity tests
None
7. Medical history 3 Usual childhood diseases. Tonsillectiony & Adenoidectomy
a
1932. Influenza 1918. Hay fever(slight) summers of 1938. & 1942.
&
No history of Hheumatic fever or Asthma.
8. Eyes
Normai
Distant vision : Right 20/
40
correctible to 20/
by 4
(Snellen type) left 20/
40
correctible to 20/
by 4
Near vision : Right J#
1
correctible to J#
by 4
1
(Jaeger type) Left J#
correctible to J#
by 4
Not döne
Left
Not done
Refraction 5 (under cycloplegic) : Right
Color perception (red and green) Normal
Normal
9. Ears
Hearing (low conversational voice) : Right 20 /20. Left 20 /20. Audiometer (percent loss): Right- Left-
10. Nose and throat
Normal
11. Teeth 7 Right (Examinee's) Left
Indicate: Restorable carious teeth by o; nonrestorable carious
7
6
5
4
3
2
1
1
2
3
4
5
6
7
teeth by /: missing natural teeth by X.
15 14 13 12 11 10 9 9 10 11
121:
14
15
Remarks, including other defects
None
Classification
IV
Prosthetic dental appliances
None
Good
Figure
Stocky
Frame
Heavy
12. Posture
(Slender, medium, stocky, obese)
(Light, medium, heavy)
(Excellent, good. fair, bad)
13. Temperature 97.8 Height63 inches. Weight 130 pounds. Chest; Rest 34 inches; inspiration 36 inches ;
expiration 32 inches. Abdomen 28 inches.
14, Cardiovascular system : Heart
Normal
Blood pressure : S. 95
D.
68
Pulse : Rate-Sitting 64
Immediately after exercise 88
Two minutes after exercise
66
Character
Full and regular
Normal
Varicose veins
None
Arteries
15. Respiratory system
Normal
16. X-ray of chest 8
Negative
17. Skin and lymphatics Normal
Endocrine system
Normal
18. Bones, joints, and muscles. ormal
n
Feet
ormal
19. Abdominal viscera
Normal
20. Hernia None
Hemorrhoids
None
Regular Army National Guard Officer' s Reserve Corps; Reserve Officer's Training Corps.
Appointment. promotion. retirement. annual. active duty, special.
8
3
If If annual annual physical examination. record only distant and near vision, and state whether defect is properly corrected.
physical examination, record only for past year.
4
5
When indicated.
O
5
Not If rejected required for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General.
for annual physical examination.
7
8
Required for candidates for commission.
w o. A.G o. FORM NO.63
16-10006
O
REPRODUCED
HQ. s.o.s. E.T.O.
-
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"ocrText": "?\n+\nREPORT OF PHYSICAL EXAMINATION\n(See AR 40-100 and 40-105)\nI\nche Instructions. Regular Army National Guard. or Officers Reserve Corps: and enrollment in the Reserve Otficers Training Corps. Use typewriter if practicable.\nUnless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant ofticers applicants for Attach appointment plain additional as such in\na\nsheets if required.\n1. Britton\nIda\n(None\n(Serial number)\na\n(Last name)\n(First name)\n(Middle initial)\nCivilian applicant for appointment\nAge\n32\nYears of service\n2\n(Grade)\n(Organization and arm or service)\n(Nearest birthday)\n(Whole number only)\n3. Nature of examination 1 Appointment\nComponent of Army\n2\nArmy of U.S.\n4. Typhoid vaccination. No. series completed\n3\nLast series\nNevember\n,19 40\nM\n5. Date of last smallpox vaccination November 1935 Type of\nreaction\nVaccinia\n6. Other vaccination or immunity tests\nNone\n7. Medical history 3 Usual childhood diseases. Tonsillectiony & Adenoidectomy\na\n1932. Influenza 1918. Hay fever(slight) summers of 1938. & 1942.\n&\nNo history of Hheumatic fever or Asthma.\n8. Eyes\nNormai\nDistant vision : Right 20/\n40\ncorrectible to 20/\nby 4\n(Snellen type) left 20/\n40\ncorrectible to 20/\nby 4\nNear vision : Right J#\n1\ncorrectible to J#\nby 4\n1\n(Jaeger type) Left J#\ncorrectible to J#\nby 4\nNot döne\nLeft\nNot done\nRefraction 5 (under cycloplegic) : Right\nColor perception (red and green) Normal\nNormal\n9. Ears\nHearing (low conversational voice) : Right 20 /20. Left 20 /20. Audiometer (percent loss): Right- Left-\n10. Nose and throat\nNormal\n11. Teeth 7 Right (Examinee's) Left\nIndicate: Restorable carious teeth by o; nonrestorable carious\n7\n6\n5\n4\n3\n2\n1\n1\n2\n3\n4\n5\n6\n7\nteeth by /: missing natural teeth by X.\n15 14 13 12 11 10 9 9 10 11\n121:\n14\n15\nRemarks, including other defects\nNone\nClassification\nIV\nProsthetic dental appliances\nNone\nGood\nFigure\nStocky\nFrame\nHeavy\n12. Posture\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n(Excellent, good. fair, bad)\n13. Temperature 97.8 Height63 inches. Weight 130 pounds. Chest; Rest 34 inches; inspiration 36 inches ;\nexpiration 32 inches. Abdomen 28 inches.\n14, Cardiovascular system : Heart\nNormal\nBlood pressure : S. 95\nD.\n68\nPulse : Rate-Sitting 64\nImmediately after exercise 88\nTwo minutes after exercise\n66\nCharacter\nFull and regular\nNormal\nVaricose veins\nNone\nArteries\n15. Respiratory system\nNormal\n16. X-ray of chest 8\nNegative\n17. Skin and lymphatics Normal\nEndocrine system\nNormal\n18. Bones, joints, and muscles. ormal\nn\nFeet\normal\n19. Abdominal viscera\nNormal\n20. Hernia None\nHemorrhoids\nNone\nRegular Army National Guard Officer' s Reserve Corps; Reserve Officer's Training Corps.\nAppointment. promotion. retirement. annual. active duty, special.\n8\n3\nIf If annual annual physical examination. record only distant and near vision, and state whether defect is properly corrected.\nphysical examination, record only for past year.\n4\n5\nWhen indicated.\nO\n5\nNot If rejected required for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General.\nfor annual physical examination.\n7\n8\nRequired for candidates for commission.\nw o. A.G o. FORM NO.63\n16-10006\nO\nREPRODUCED\nHQ. s.o.s. E.T.O.\n-"
}