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REPORT QF PHYSICAL EXAMINATION
(See AR 40-100 and 40-105)
che Regular Army National Guard. or Officers Reserve Corps and enrollment in the Reserve Officers' Training Corps. Use typewriter if practicable. Attach plain
Instructions Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant ofticers applicants for appointment additional as such in
sheets if required.
1. Ralph
Susan
S.
(Last name)
(First name)
(Middle initial)
(Serial number)
2 Civilian applicant for appointment
Age
23
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 2
Last series January
,19 41
5. Date of last smallpox vaccination January 1941
Type of reaction
Immune
6. Other vaccination or immunity tests
Typhus 1942
7. Medical history 3
Usual childhood diseases
Tonsils and Adenoids 1924
Incision and drainage pacro-caccyxgeal abscess -1940.
Pneumonia 1939
No history of Asthma, Hay fever or Rheumatic 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) : 6 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
11. Teeth: 7
Right
(Examinee's)
Left
Indicate: Restorable carious teeth by O: nonrestorable carious
X 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
teeth by / ; missing natural teeth by X.
15 13 12 11 10 9 9 10 11 14 15 1y
Remarks, including other defects None
Classification
IV
Prosthetic dental appliances
None
Good
12. Posture
Figure
Medium
Frame
Light
(Excellent, good. fair, bad)
(Slender, medium, stocky, obese)
(Light, medium, heavy)
13. Temperature 98.4 Height 62 inches. Weight 107 pounds. Chest ; Rest 29 inches; inspiration 31 inches ;
expiration 28 inches. Abdomen 27 inches.
14, Cardiovascular system Heart
Normal
Blood pressure : S. 110
, D.
75
Pulse : Rate-Sitting 80
Immediately after exercise. 112
Two minutes after exercise
82
Character
Full and regular
Arteries Normal
Varicose veins
None
15. Respiratory system
Normal
16. X-ray of chest 8
Negative
17. Skin and lymphatics Normal
Endocrine system
Normal
18. Bones, joints, and muscles
Normal
Feet Normal
19. Abdominal viscera Normal
20. Hernia None
Hemorrhoids None
1
Appointment. promotion. retirement. annual. active duty, special.
2 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.
5
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
16-10006
REPRODUCED
HO. S.O.S. E.T.O.
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"ocrText": "REPORT QF PHYSICAL EXAMINATION\n(See AR 40-100 and 40-105)\nche Regular Army National Guard. or Officers Reserve Corps and enrollment in the Reserve Officers' Training Corps. Use typewriter if practicable. Attach plain\nInstructions Unless otherwise prescribed. this form will be used for all physical examinations of officers. nurses or warrant ofticers applicants for appointment additional as such in\nsheets if required.\n1. Ralph\nSusan\nS.\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\n2 Civilian applicant for appointment\nAge\n23\nYears of service\n(Grade)\n(Organization and arm or service)\n(Nearest birthday)\n(Whole number only)\n3. Nature of examination 1 Appointment\nComponent of Army 2 Army of U.S.\n4. Typhoid vaccination. No. series completed 2\nLast series January\n,19 41\n5. Date of last smallpox vaccination January 1941\nType of reaction\nImmune\n6. Other vaccination or immunity tests\nTyphus 1942\n7. Medical history 3\nUsual childhood diseases\nTonsils and Adenoids 1924\nIncision and drainage pacro-caccyxgeal abscess -1940.\nPneumonia 1939\nNo history of Asthma, Hay fever or Rheumatic fever.\n8. Eyes\nNormal\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) : 6 Right\nNot done\nLeft\nNot done\nColor perception (red and green)\nNormal\n9. Ears\nNormal\nHearing (low conversational voice) : Right\n20/20. Left 20 /20. Audiometer (percent loss): Right.-Left.- - -\n10. Nose and\n11. Teeth: 7\nRight\n(Examinee's)\nLeft\nIndicate: Restorable carious teeth by O: nonrestorable carious\nX 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8\nteeth by / ; missing natural teeth by X.\n15 13 12 11 10 9 9 10 11 14 15 1y\nRemarks, including other defects None\nClassification\nIV\nProsthetic dental appliances\nNone\nGood\n12. Posture\nFigure\nMedium\nFrame\nLight\n(Excellent, good. fair, bad)\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n13. Temperature 98.4 Height 62 inches. Weight 107 pounds. Chest ; Rest 29 inches; inspiration 31 inches ;\nexpiration 28 inches. Abdomen 27 inches.\n14, Cardiovascular system Heart\nNormal\nBlood pressure : S. 110\n, D.\n75\nPulse : Rate-Sitting 80\nImmediately after exercise. 112\nTwo minutes after exercise\n82\nCharacter\nFull and regular\nArteries Normal\nVaricose veins\nNone\n15. Respiratory system\nNormal\n16. X-ray of chest 8\nNegative\n17. Skin and lymphatics Normal\nEndocrine system\nNormal\n18. Bones, joints, and muscles\nNormal\nFeet Normal\n19. Abdominal viscera Normal\n20. Hernia None\nHemorrhoids None\n1\nAppointment. promotion. retirement. annual. active duty, special.\n2 Regular Army National Guard Officer S Reserve Corps; Reserve Officer's Training Corps.\n3 If annual physical examination, record only for past year.\n4\nIf annual physical examination. record only distant and near vision, and state whether defect is properly corrected.\n5 When indicated.\n5\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 Required for candidates for commission\n16-10006\nREPRODUCED\nHO. S.O.S. E.T.O."
}