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REPORT OF PHYSICAL EXAMINATION
(See AR 40-100 and 40-105)
M
che Regular Army, National Guard. or Officers Reserve Corps and enrollment in the Reserve Officers' Training Corps. Use typewriter if practicable. Attach plain additional
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
a
sheets if required.
Dodds
M
---
1.
Mary
(Last name)
(First name)
(Middle initial)
(Serial number)
Civilian applicant for appointment
26
---
2
Age
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 , U.S.
4. Typhoid vaccination. No. series completed
3
Last series
August
19 41
M
5. Date of last smallpox vaccination August 1941
Type of reaction
Vaccinia
6. Other vaccination or immunity tests
Typhus, March
1941
7. Medical history
3 Measles, Chicken-pox_ , Whoopinf-cough in
childhood.
ar
No operations.
No history of Hay-fever, Rheumatic-fever or Asthma.
9
e
+
Normal
8. Eyes
Distant vision : Right 20/
20
correctible to 20/
by 4
20
(Snellen type) left 20/
correctible to 20/
by 4
1
Near vision : Right J#
correctible to J#
by 4
1
(Jaeger type) Left J#
correctible to J#
by 4
Left
---
Refraction 5 (under cycloplegic) : Right
Color perception (red and green) 6
Normal
Normal
9. Ears
Hearing (low conversational voice) : Right
20
/20. Left
20
/20. Audiometer (percent loss):
10. Nose and throat
Normal
11. Teeth:
Right
(Examinee's)
Left
Indicate: Restorable carious teeth by o; nonrestorable carious
8 7
5
4
3
2
1
1
2
3
4
5
6
7
8
teeth by /: missing natural teeth by X.
16 15 13 12 11 10 9 9 10 2 14 15
None
Remarks, including other defects
Classification
IV
Prosthetic dental appliances
None
Good
Figure
Medium
Frame
Medium
12. Posture
(Excellent, good. fair, bad)
(Slender, medium, stocky, obese)
(Light, medium, heavy)
13. Temperature 97.2 Height 65 inches. Weight pounds. Chest; Rest 33 1 2inches: inspiration 35 $ inches:
expiration 33 inches. Abdomen 30 inches.
14, Cardiovascular system : Heart Normal
Blood pressure S.
105
D
65
Pulse : Rate-Sitting 75
Immediately after exercise 92
,
Two minutes after exercise
82
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 Pes planus Mod., N.S.
19. Abdominal viscera
Normal
20. Hernia
None
None
Hemorrhoids
Appointment. promotion. retirement annual active duty, special.
Regular Army National Guard Officer' Reserve Corps; Reserve Officer's Training Corps.
3
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.
5
When indicated.
6 If rejected for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General
Not required for annual physical examination.
5
8
Required for candidates for commission
w D. A.G O. FORM NO.63
W
REPRODUCED
HO S.O.S. E.T.O.
w
N
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"ocrText": "D\na\nREPORT OF PHYSICAL EXAMINATION\n(See AR 40-100 and 40-105)\nM\nche Regular Army, National Guard. or Officers Reserve Corps and enrollment in the Reserve Officers' Training Corps. Use typewriter if practicable. Attach plain additional\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\na\nsheets if required.\nDodds\nM\n---\n1.\nMary\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\nCivilian applicant for appointment\n26\n---\n2\nAge\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\nArmy , U.S.\n4. Typhoid vaccination. No. series completed\n3\nLast series\nAugust\n19 41\nM\n5. Date of last smallpox vaccination August 1941\nType of reaction\nVaccinia\n6. Other vaccination or immunity tests\nTyphus, March\n1941\n7. Medical history\n3 Measles, Chicken-pox_ , Whoopinf-cough in\nchildhood.\nar\nNo operations.\nNo history of Hay-fever, Rheumatic-fever or Asthma.\n9\ne\n+\nNormal\n8. Eyes\nDistant vision : Right 20/\n20\ncorrectible to 20/\nby 4\n20\n(Snellen type) left 20/\ncorrectible to 20/\nby 4\n1\nNear vision : Right J#\ncorrectible to J#\nby 4\n1\n(Jaeger type) Left J#\ncorrectible to J#\nby 4\nLeft\n---\nRefraction 5 (under cycloplegic) : Right\nColor perception (red and green) 6\nNormal\nNormal\n9. Ears\nHearing (low conversational voice) : Right\n20\n/20. Left\n20\n/20. Audiometer (percent loss):\n10. Nose and throat\nNormal\n11. Teeth:\nRight\n(Examinee's)\nLeft\nIndicate: Restorable carious teeth by o; nonrestorable carious\n8 7\n5\n4\n3\n2\n1\n1\n2\n3\n4\n5\n6\n7\n8\nteeth by /: missing natural teeth by X.\n16 15 13 12 11 10 9 9 10 2 14 15\nNone\nRemarks, including other defects\nClassification\nIV\nProsthetic dental appliances\nNone\nGood\nFigure\nMedium\nFrame\nMedium\n12. Posture\n(Excellent, good. fair, bad)\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n13. Temperature 97.2 Height 65 inches. Weight pounds. Chest; Rest 33 1 2inches: inspiration 35 $ inches:\nexpiration 33 inches. Abdomen 30 inches.\n14, Cardiovascular system : Heart Normal\nBlood pressure S.\n105\nD\n65\nPulse : Rate-Sitting 75\nImmediately after exercise 92\n,\nTwo minutes after exercise\n82\nCharacter Full and Regular\nArteries\nNormal\nVaricose veins None\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 Pes planus Mod., N.S.\n19. Abdominal viscera\nNormal\n20. Hernia\nNone\nNone\nHemorrhoids\nAppointment. promotion. retirement annual active duty, special.\nRegular Army National Guard Officer' Reserve Corps; Reserve Officer's Training Corps.\n3\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.\n5\nWhen indicated.\n6 If rejected for appointment in Regular Army because of malocclusion send plaster models to the Surgeon General\nNot required for annual physical examination.\n5\n8\nRequired for candidates for commission\nw D. A.G O. FORM NO.63\nW\nREPRODUCED\nHO S.O.S. E.T.O.\nw\nN"
}