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a
geborg
REPORT OF PHYSICAL EXAMINATION
5
(See AR 40-100 and 40-105)
C
es
e
Guard, Instructions. or Officers Unless Reserve otherwise Corps; and prescribed, enrollment this form in the will Reserve be used Officers for all physical Training examinations Corps. Use of typewriter officers, nurses, if practicable. or warrant officers; Attach plain applicants additional for appointment sheets if required. as such in the Regular Army, National
1.
Bacon
Frances
A.
---
(Last name)
(First name)
(Middle initial)
(Serial number)
2.
Civilian applicant for appointment
Age
27
Years of service.
----
A
(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
4
Last series
December
19.40
,
5. Date of last smallpox vaccination Pecember 1940
Type of reaction
Immune
C
6. Other vaccination or immunity tests
None
e
7.
Medical history 3 Measles, Mumps, Chicken Pox, Whooping Cough in Childhood. Tonsillectomy
and Adenoids 1919, Appendectomy 1937.
No histroy Hay Fever, Rheumatic fever,
Asthma.
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
(Jaeger type) Left J# 1
correctible to J#
by 4
Refraction 5 (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
Normal
11. Teeth: 7
Right
(Examinee's)
Left
x 7 6 5 4 3 2 1 1 2 3 4 5 6 7
Indicate: Restorable carious teeth by O: nonrestorable carious teeth
by /; missing natural teeth by X.
16 15 14 13 12 11 10 9 9 10 11 12 13 14 15
Remarks, including other defects
None
Classification
II
Prosthetic dental appliances
None
12. Posture
Good
Figure
Stocky
Frame
Heavy
(Excellent, good, fair, bad)
(Slender, medium, stocky, obese)
(Light, medium, heavy)
13.
Temperature 97.8 Height 62 3/Linches. Weight 155 pounds. Chest: Rest 35 inches; inspiration 36 2 inches;
expiration- 34 2 inches. Abdomen 31 inches.
14. Cardiovascular system: Heart
Normal
Blood pressure: S.
95
D. 55
Pulse: te-Sitting
68
Immediately after exercise 96
Two minutes after exercise
64
Character
Full and Regular
Arteries
Normal
Varicose veins
None
15. Respiratory system
Normal
16. X-ray of chest 8
"ormal
17. Skin and lymphatics
Normal
Endocrine system
Normal
18. Bones, joints, and muscles
Normal
Feet Pes planus, moderate, N. S.
19. Abdominal viscera
Normal
20. Hernia
None
Hemorrhoids
None
1 Appointment, promotion, retirement, annual, active duty, special.
2 3 Regular If Army; National Guard; Officers' Reserve Corps; Reserve Officers' Training Corps.
annual physical examination, record only for past year.
5 When indicated.
If annual physical examination, record only distant and near vision, and state whether defect is properly corrected.
6 Not required for annual physical examination.
7 8 If rejected for appointment in Regular Army because of malocclusion, send plaster models to the Surgeon General.
Required for candidates for commission.
W. D., A. G. o. Form No. 63
August 1, 1939
16-10006
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"ocrText": "P\nF\nT\npo\na\ngeborg\nREPORT OF PHYSICAL EXAMINATION\n5\n(See AR 40-100 and 40-105)\nC\nes\ne\nGuard, Instructions. or Officers Unless Reserve otherwise Corps; and prescribed, enrollment this form in the will Reserve be used Officers for all physical Training examinations Corps. Use of typewriter officers, nurses, if practicable. or warrant officers; Attach plain applicants additional for appointment sheets if required. as such in the Regular Army, National\n1.\nBacon\nFrances\nA.\n---\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\n2.\nCivilian applicant for appointment\nAge\n27\nYears of service.\n----\nA\n(Grade)\n(Organization and arm or service)\n(Nearest birthday)\n(Whole number only)\n-\n3. Nature of examination 1\nAppointment\nComponent of Army 2 Army of U.S.\n4. Typhoid vaccination. No. series completed\n4\nLast series\nDecember\n19.40\n,\n5. Date of last smallpox vaccination Pecember 1940\nType of reaction\nImmune\nC\n6. Other vaccination or immunity tests\nNone\ne\n7.\nMedical history 3 Measles, Mumps, Chicken Pox, Whooping Cough in Childhood. Tonsillectomy\nand Adenoids 1919, Appendectomy 1937.\nNo histroy Hay Fever, Rheumatic fever,\nAsthma.\n8. Eyes\nNormal\nDistant vision: Right 20/ 20\ncorrectible to 20/\nby 4\n(Snellen type) Left 20/ 20\ncorrectible to 20/\nby 4\nNear vision: Right J# 1\ncorrectible to J#\nby 4\n(Jaeger type) Left J# 1\ncorrectible to J#\nby 4\nRefraction 5 (under cycloplegic): Right\nNot Done\nLeft\nNot Done.\nColor perception (red and green)\n6\nNormal\n9. Ears\nNormal\nHearing (low conversational voice): Right\n20\n/20. Left\n20 /20. Audiometer (percent loss): Right Left\n10. Nose and throat\nNormal\n11. Teeth: 7\nRight\n(Examinee's)\nLeft\nx 7 6 5 4 3 2 1 1 2 3 4 5 6 7\nIndicate: Restorable carious teeth by O: nonrestorable carious teeth\nby /; missing natural teeth by X.\n16 15 14 13 12 11 10 9 9 10 11 12 13 14 15\nRemarks, including other defects\nNone\nClassification\nII\nProsthetic dental appliances\nNone\n12. Posture\nGood\nFigure\nStocky\nFrame\nHeavy\n(Excellent, good, fair, bad)\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n13.\nTemperature 97.8 Height 62 3/Linches. Weight 155 pounds. Chest: Rest 35 inches; inspiration 36 2 inches;\nexpiration- 34 2 inches. Abdomen 31 inches.\n14. Cardiovascular system: Heart\nNormal\nBlood pressure: S.\n95\nD. 55\nPulse: te-Sitting\n68\nImmediately after exercise 96\nTwo minutes after exercise\n64\nCharacter\nFull and Regular\nArteries\nNormal\nVaricose veins\nNone\n15. Respiratory system\nNormal\n16. X-ray of chest 8\n\"ormal\n17. Skin and lymphatics\nNormal\nEndocrine system\nNormal\n18. Bones, joints, and muscles\nNormal\nFeet Pes planus, moderate, N. S.\n19. Abdominal viscera\nNormal\n20. Hernia\nNone\nHemorrhoids\nNone\n1 Appointment, promotion, retirement, annual, active duty, special.\n2 3 Regular If Army; National Guard; Officers' Reserve Corps; Reserve Officers' Training Corps.\nannual physical examination, record only for past year.\n5 When indicated.\nIf annual physical examination, record only distant and near vision, and state whether defect is properly corrected.\n6 Not required for annual physical examination.\n7 8 If rejected for appointment in Regular Army because of malocclusion, send plaster models to the Surgeon General.\nRequired for candidates for commission.\nW. D., A. G. o. Form No. 63\nAugust 1, 1939\n16-10006"
}