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REPORT OF PHYSICAL EXAMINATION
(See AR 40-100 and 40-105)
Instructions Unless or therwise 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 Officers' Training Corps. Use typewriter if practicable. Attach plain additional
sheets if required.
1.
Geekie
Ann
G
(Last name)
(First name)
(Middle initial)
(Serial number)
2
Civilian applicant for apointment
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
July
19 41
5. Date of last smallpox vaccination July 1941
Type of reaction
Vaccinia
6. Other vaccination or immunity tests
one
7. Medical history 3
Usual childhood diseases:
Tonsillectomy and Adenoid 1940
No history of Asthma, Rheumatic-fever 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
(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
Right
(Examinee's)
Left
Indicate: Restorable carious teeth by o ; nonrestorable carious
teeth by / ; missing natural teeth by X.
13
Remarks, including other defects
None
Classification IV
Prosthetic dental appliances Full upper and lower Denture, Servicable:
12. Posture
Good
Figure
Medium
Frame
Light
(Excellent, good. fair, bad)
(Slender, medium, stocky, obese)
(Light, medium, heavy)
13. Temperature 97 Height 61 inches. Weight 110 pounds. Chest Rest29 inches inspiration 32 inches
expiration 29 inches. Abdomen 29 inches.
14, Cardiovascular system : Heart
Normal
Blood pressure : S.
110
D.
68
Pulse : Rate-Sitting
78
Immediately after exercise
Two minutes after exercise
80
Character
Full and regular
Arteries
Normal
Varicose veins
None
15. Respiratory system
Normal
16. X-ray of chest 8
Normal
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.
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.
d
Required for candidates for commission.
A.G.O. FORM NO.63
16-10006
REPRODUCED
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 or therwise prescribed. this form will be used for all physical examinations of officers, nurses or warrant officers: applicants for appointment as such in\nche Regular Army. National Guard. or Officers Reserve Corps: and enrollment in the Reserve Officers' Training Corps. Use typewriter if practicable. Attach plain additional\nsheets if required.\n1.\nGeekie\nAnn\nG\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\n2\nCivilian applicant for apointment\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\nAppointment\nComponent of Army\n2\nArmy of U.S.\n4. Typhoid vaccination. No. series completed\n2\nLast series\nJuly\n19 41\n5. Date of last smallpox vaccination July 1941\nType of reaction\nVaccinia\n6. Other vaccination or immunity tests\none\n7. Medical history 3\nUsual childhood diseases:\nTonsillectomy and Adenoid 1940\nNo history of Asthma, Rheumatic-fever or Hay-fever.\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#\n1\ncorrectible to J#\nby 4\n(Jaeger type) Left J#\n1\ncorrectible to J#\nby 4\nRefraction 5 (under cycloplegic) : Right\nNot done\nLeft\nNot done\nColor perception (red and green) 6\nNormal\n9. Ears\nNormal\nHearing (low conversational voice) : Right 20 /20. Left 20 /20. Audiometer (percent loss): Right - Left -\n10. Nose and throat\nNormal\n11. Teeth\nRight\n(Examinee's)\nLeft\nIndicate: Restorable carious teeth by o ; nonrestorable carious\nteeth by / ; missing natural teeth by X.\n13\nRemarks, including other defects\nNone\nClassification IV\nProsthetic dental appliances Full upper and lower Denture, Servicable:\n12. Posture\nGood\nFigure\nMedium\nFrame\nLight\n(Excellent, good. fair, bad)\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n13. Temperature 97 Height 61 inches. Weight 110 pounds. Chest Rest29 inches inspiration 32 inches\nexpiration 29 inches. Abdomen 29 inches.\n14, Cardiovascular system : Heart\nNormal\nBlood pressure : S.\n110\nD.\n68\nPulse : Rate-Sitting\n78\nImmediately after exercise\nTwo minutes after exercise\n80\nCharacter\nFull and regular\nArteries\nNormal\nVaricose veins\nNone\n15. Respiratory system\nNormal\n16. X-ray of chest 8\nNormal\n17. Skin and lymphatics\nNormal\nEndocrine system\nNormal\n18. Bones, joints, and muscles\nNormal\nFeet Normal\n19. Abdominal viscera\nNormal\n20. Hernia\nNone\nHemorrhoids\nNone\n1\nAppointment. promotion. retirement. annual. active duty, special.\n2\nRegular 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\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.\nd\nRequired for candidates for commission.\nA.G.O. FORM NO.63\n16-10006\nREPRODUCED\nHO. S.O.S. E.T.O."
}