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REPORT OF PHYSICAL EXAMINATION
P
(See AR 40-100 and 40-105)
4.
Instructions, - Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant ofticers 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. Martin
Ruth
M.
(Last name)
(First name)
(Middle initial)
(Serial number)
2 Civilian applicant for apointment
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 J.S.
4. Typhoid vaccination. No. series completed
3
Last series
May
,19 41
M
5. Date of last smallpox vaccination
May 1941
Type of reaction
Immune
6. Other vaccination or immunity tests
None
7. Medical history 3 Usual childhood diseases; Family history of TB.
ar
Appendectomy. 1933
Tonsils and Adenoids 1931
Empyema 1918-- Influe nza 1918
No. history of Asthma, Hay. fever or Rheumatic fever.
8. Eyes Norma 1
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
Refraction5 (under cycloplegic) : Right
Not done
Left
Not done
Color perception (red and green)
Normal
9. Ears
Normal
Hearing (low conversational voice) Right
20
/20.
Left
20/20. Audiometer (percent loss) Right -Left -
10. Nose and throat Deviated septum, left- - N.S.
11. Teeth
Right
(Examinee's)
Left
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
Indicate: Restorable carious teeth by o : nonrestorable carious
teeth by / missing natural teeth by X.
16 15 14 13 12 11 10 9 91011 1213141516
Remarks, including other defects None
Classification
II
Prosthetic dental appliances Partial upper denture-Serviceable.
12. Posture
Good
Figure
Slender
Frame
Light
(Excellent, good. fair, bad)
(Slender, medium, stocky, obese)
(Light, medium, heavy)
13. Temperature 97. 2Height 66. inches. Weightllo pounds. Chest; Rest.30zinches; inspiration 32 inches
;
expiration 28 inches. Abdomen 27 inches.
14, Cardiovascular system : Heart Normal
Blood pressure : S. 85 , D 45
Pulse : Rate-Sitting 75
Immediately after exercise. 96
Two minutes after exercise 68
Character Full and regular
Arteries Normal
Varicose veins
None
15. Respiratory system Normal
16. X-ray of chest 8 (A) See 24, over:
17. Skin and lymphatics Normal
Endocrine system
Normal
18. Bones, joints, and muscles
Norma 1
Feet Normal
19. Abdominal viscera Normal
20. Hernia None
Hemorrhoids
None
1
Appointment. promotion. retirement. annual active duty, special.
Regular Army National Guard Officer's Reserve Corps: Reserve Officer's Training Corps.
3
If
annual physical examination, record only for past year.
4 If annual physical examination. record only distant and near vision, and state whether defect is properly corrected.
5
When indicated.
6
Not required for annual physical examination.
7 If rejected for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General
8
Required for candidates for commission.
w.o.,
16-10006
REPRODUCED
HO s.o.s E.T.O.
9
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"ocrText": "3\nar\n+\ns\nREPORT OF PHYSICAL EXAMINATION\nP\n(See AR 40-100 and 40-105)\n4.\nInstructions, - Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant ofticers 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. Martin\nRuth\nM.\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\n2 Civilian applicant for apointment\nAge\n30\nYears of service\n-\n(Grade)\n(Organization and arm or service)\n(Nearest birthday)\n(Whole number only)\n3. Nature of examination\n1\nAppointment\nComponent of Army 2\nArmy of J.S.\n4. Typhoid vaccination. No. series completed\n3\nLast series\nMay\n,19 41\nM\n5. Date of last smallpox vaccination\nMay 1941\nType of reaction\nImmune\n6. Other vaccination or immunity tests\nNone\n7. Medical history 3 Usual childhood diseases; Family history of TB.\nar\nAppendectomy. 1933\nTonsils and Adenoids 1931\nEmpyema 1918-- Influe nza 1918\nNo. history of Asthma, Hay. fever or Rheumatic fever.\n8. Eyes Norma 1\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#\n1\ncorrectible to J#\nby 4\n(Jaeger type) Left J#\n1\ncorrectible to J#\nby 4\nRefraction5 (under cycloplegic) : Right\nNot done\nLeft\nNot done\nColor perception (red and green)\nNormal\n9. Ears\nNormal\nHearing (low conversational voice) Right\n20\n/20.\nLeft\n20/20. Audiometer (percent loss) Right -Left -\n10. Nose and throat Deviated septum, left- - N.S.\n11. Teeth\nRight\n(Examinee's)\nLeft\n8\n7\n6\n5\n4\n3\n2\n1\n1\n2\n3\n4\n5\n6\n7\n8\nIndicate: Restorable carious teeth by o : nonrestorable carious\nteeth by / missing natural teeth by X.\n16 15 14 13 12 11 10 9 91011 1213141516\nRemarks, including other defects None\nClassification\nII\nProsthetic dental appliances Partial upper denture-Serviceable.\n12. Posture\nGood\nFigure\nSlender\nFrame\nLight\n(Excellent, good. fair, bad)\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n13. Temperature 97. 2Height 66. inches. Weightllo pounds. Chest; Rest.30zinches; inspiration 32 inches\n;\nexpiration 28 inches. Abdomen 27 inches.\n14, Cardiovascular system : Heart Normal\nBlood pressure : S. 85 , D 45\nPulse : Rate-Sitting 75\nImmediately after exercise. 96\nTwo minutes after exercise 68\nCharacter Full and regular\nArteries Normal\nVaricose veins\nNone\n15. Respiratory system Normal\n16. X-ray of chest 8 (A) See 24, over:\n17. Skin and lymphatics Normal\nEndocrine system\nNormal\n18. Bones, joints, and muscles\nNorma 1\nFeet Normal\n19. Abdominal viscera Normal\n20. Hernia None\nHemorrhoids\nNone\n1\nAppointment. promotion. retirement. annual active duty, special.\nRegular Army National Guard Officer's Reserve Corps: Reserve Officer's Training Corps.\n3\nIf\nannual physical examination, record only for past year.\n4 If annual physical examination. record only distant and near vision, and state whether defect is properly corrected.\n5\nWhen indicated.\n6\nNot required for annual physical examination.\n7 If rejected for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General\n8\nRequired for candidates for commission.\nw.o.,\n16-10006\nREPRODUCED\nHO s.o.s E.T.O.\n9"
}