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REPORT OF PHYSICAL EXAMINATION
(See AR 40-100 and 40-105)
Instructions. Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant officers applicants for appointment as such in
che
Regular Army National Guard, or Officers Reserve Corps and enrollment in the Reserve Otficers' Training Corps. Use typewriter if practicable: Attach plain additional
sheets if required.
1. Wilson
Catherine
J.
---
(Last name)
(First name)
(Middle initial)
(Serial number)
2
Civilian applicant for appointment
Age
30
Years of service
(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
May
5. Date of last smallpox vaccination
May 1947
Type of reaction
Immune
6. Other vaccination or immunity tests Typhus March 1941
7. Medical history 3
Usual childhood diseases
Appendectomy 1918
Tonsi llectomy
1925
Rheumatisi (slight) 1929
No history of Asthma, or Hay fever.
8. Eyes Normal
Distant vision : Right 20/
20
correctible to 20/
by 4
(Snellen type) left 20/
20
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
Refraction5 (under cycloplegic) : Right
Not done
Left
Not done
Color perception (red and green)6
Normal
9. Ears
Normal
Hearing (low conversational voice) : Right
20
/20.
Left 20 /20. Audiometer (percent loss): Right -Left.
10. Nose and throat Tonsils slightly enlarged N.S.
11. Teeth
Right
(Examinee's)
Left
x
7
x
5
4
3
2
1
1
2
3
4
x
6
7
Indicate: Restorable carious teeth by o ; nonrestorable carious
teeth by / missing natural teeth by X.
1)R 15 x 1X 12 11 10 9 9 10 11 121 15 1
Remarks, including other defects
None
Classification IV
Prosthetic dental appliances
None
12. Posture
Good
Figure
Stocky
Frame
Medium
(Excellent, good. fair, bad)
(Slender. medium, stocky, obese)
(Light, medium, heavy)
13. Temperature 97.4 Height 62 inches. Weight 134 pounds. Chest; Rest 352 inches; inspiration 37 inches;
expiration 33 inches. Abdomen 35 inches.
14, Cardiovascular system : Heart
normal
Blood pressure : S. 105
D. 75
Pulse : Rate-Sitting
68
Immediately after exercise 96
Two minutes after exercise 76
Character
Full and regular
Arteries
Normal
Varicose veins
None
15. Respiratory system
Normal
16. X-ray of chest 8 Negative
17. Skin and lymphatics McBurneys Scar-N.S.
Endocrine system
Normal
18. Bones, joints, and muscles
Normal
Feet
Normal
19. Abdominal viscera
Normal
20. Hernia None
Hemorrhoids
None
Appointment. promotion retirement. annual. active duty, special.
Regular Army National Guard Officer Reserve Corps; Reserve Officer's Training Corps.
If annual physical examination, record only for past year.
If annual physical examination. record only distant and near vision, and state whether defect is properly corrected
When indicated.
Not required for annual physical examination.
If rejected for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General
Required for candidates for commission.
D.. A.G O. FORM NO.63
REPRODUCED
16-10006
HO. s.o.s. E.T.O.
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"ocrText": "REPORT OF PHYSICAL EXAMINATION\n(See AR 40-100 and 40-105)\nInstructions. Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant officers applicants for appointment as such in\nche\nRegular Army National Guard, or Officers Reserve Corps and enrollment in the Reserve Otficers' Training Corps. Use typewriter if practicable: Attach plain additional\nsheets if required.\n1. Wilson\nCatherine\nJ.\n---\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\n2\nCivilian applicant for appointment\nAge\n30\nYears of service\n(Grade)\n(Organization and arm or service)\n(Nearest birthday)\n(Whole number only)\n3. Nature of examination 1\nAppointment\nComponent of Army 2 Army of U.S.\n4. Typhoid vaccination. No. series completed\n3\nLast series\nMay\n5. Date of last smallpox vaccination\nMay 1947\nType of reaction\nImmune\n6. Other vaccination or immunity tests Typhus March 1941\n7. Medical history 3\nUsual childhood diseases\nAppendectomy 1918\nTonsi llectomy\n1925\nRheumatisi (slight) 1929\nNo history of Asthma, or Hay fever.\n8. Eyes Normal\nDistant vision : Right 20/\n20\ncorrectible to 20/\nby 4\n(Snellen type) left 20/\n20\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\nRefraction5 (under cycloplegic) : Right\nNot done\nLeft\nNot done\nColor perception (red and green)6\nNormal\n9. Ears\nNormal\nHearing (low conversational voice) : Right\n20\n/20.\nLeft 20 /20. Audiometer (percent loss): Right -Left.\n10. Nose and throat Tonsils slightly enlarged N.S.\n11. Teeth\nRight\n(Examinee's)\nLeft\nx\n7\nx\n5\n4\n3\n2\n1\n1\n2\n3\n4\nx\n6\n7\nIndicate: Restorable carious teeth by o ; nonrestorable carious\nteeth by / missing natural teeth by X.\n1)R 15 x 1X 12 11 10 9 9 10 11 121 15 1\nRemarks, including other defects\nNone\nClassification IV\nProsthetic dental appliances\nNone\n12. Posture\nGood\nFigure\nStocky\nFrame\nMedium\n(Excellent, good. fair, bad)\n(Slender. medium, stocky, obese)\n(Light, medium, heavy)\n13. Temperature 97.4 Height 62 inches. Weight 134 pounds. Chest; Rest 352 inches; inspiration 37 inches;\nexpiration 33 inches. Abdomen 35 inches.\n14, Cardiovascular system : Heart\nnormal\nBlood pressure : S. 105\nD. 75\nPulse : Rate-Sitting\n68\nImmediately after exercise 96\nTwo minutes after exercise 76\nCharacter\nFull and regular\nArteries\nNormal\nVaricose veins\nNone\n15. Respiratory system\nNormal\n16. X-ray of chest 8 Negative\n17. Skin and lymphatics McBurneys Scar-N.S.\nEndocrine system\nNormal\n18. Bones, joints, and muscles\nNormal\nFeet\nNormal\n19. Abdominal viscera\nNormal\n20. Hernia None\nHemorrhoids\nNone\nAppointment. promotion retirement. annual. active duty, special.\nRegular Army National Guard Officer Reserve Corps; Reserve Officer's Training Corps.\nIf annual physical examination, record only for past year.\nIf annual physical examination. record only distant and near vision, and state whether defect is properly corrected\nWhen indicated.\nNot required for annual physical examination.\nIf rejected for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General\nRequired for candidates for commission.\nD.. A.G O. FORM NO.63\nREPRODUCED\n16-10006\nHO. s.o.s. E.T.O."
}