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REPORT OF PHYSICAL EXAMINATION
(See AR 40-100 and 40-105)
Instructions Unless otherwise prescribed. this form will be used tor 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. Madley
Gertrude
(Last name)
(First name)
(Middle initial)
(Serial number)
2 Civilian applicant for apointment
Age
49
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
8
Last series
October 1940
,19
5. Date of last smallpox vaccination October 1940
Type of reaction
Immune
6. Other vaccination or immunity tests None
7. Medical history 3
Usual childhood diseases
Influenza 1918
No history of Asthma, Hay fever or Rhe umati 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#
3
correctible to J#
by 4
(Jaeger type) Left J#
2
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
7 6
3
2
1
1
2
3
4
X)8
Indicate: Restorable carious teeth by o : nonrestorable carious
teeth by / missing natural teeth by X.
16
15
12
11
10
9
9
10
16
Remarks, including other defects None
Classification IV
Prosthetic dental appliances
Serviceable
12. Posture
Good
Figure
Medium
Frame
Medium
(Excellent, good, fair, bad)
(Slender, medium, stocky, obese)
(Light, medium, heavy)
13. Temperature Height 67 inches. Weight134.pounds. Chest Rest 32 inches inspiration 34 inches
expiration 31 inches. Abdomen 33 inches.
14, Cardiovascular system : Heart Normal
Blood pressure : S 140
D.
85
Pulse : Rate-Sitting
90
Immediately after exercise 105
Two minutes after exercise 84
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.
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.
.D., A.G FORM
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 otherwise prescribed. this form will be used tor 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. Madley\nGertrude\n(Last name)\n(First name)\n(Middle initial)\n(Serial number)\n2 Civilian applicant for apointment\nAge\n49\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\n8\nLast series\nOctober 1940\n,19\n5. Date of last smallpox vaccination October 1940\nType of reaction\nImmune\n6. Other vaccination or immunity tests None\n7. Medical history 3\nUsual childhood diseases\nInfluenza 1918\nNo history of Asthma, Hay fever or Rhe umati fever\n8. Eyes Normal\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#\n3\ncorrectible to J#\nby 4\n(Jaeger type) Left J#\n2\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 Normal\n11. Teeth\nRight\n(Examinee's)\nLeft\n7 6\n3\n2\n1\n1\n2\n3\n4\nX)8\nIndicate: Restorable carious teeth by o : nonrestorable carious\nteeth by / missing natural teeth by X.\n16\n15\n12\n11\n10\n9\n9\n10\n16\nRemarks, including other defects None\nClassification IV\nProsthetic dental appliances\nServiceable\n12. Posture\nGood\nFigure\nMedium\nFrame\nMedium\n(Excellent, good, fair, bad)\n(Slender, medium, stocky, obese)\n(Light, medium, heavy)\n13. Temperature Height 67 inches. Weight134.pounds. Chest Rest 32 inches inspiration 34 inches\nexpiration 31 inches. Abdomen 33 inches.\n14, Cardiovascular system : Heart Normal\nBlood pressure : S 140\nD.\n85\nPulse : Rate-Sitting\n90\nImmediately after exercise 105\nTwo minutes after exercise 84\nCharacter\nFull and regular\nArteries\nNormal\nVaricose veins\nNone\n15. Respiratory system Normal\n16. X-ray of chest 8\nNegative\n17. Skin and lymphatics\nNormal\nEndocrine system\nNormal\n18. Bones, joints, and muscles\nNormal\nFeet\nNormal\n19. Abdominal viscera\nNormal\n20. Hernia\nNone\nHemorrhoids\nNone\n1\nAppointment. promotion. retirement. annual. active duty, special.\n2 Regular Army : National Guard Officer's Reserve Corps : Reserve Officer's Training Corps.\n3\nIf annual physical examination, record only for past year.\n4\nIf\nannual 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.\n.D., A.G FORM\nREPRODUCED\nHO. S.O.S. E.T.O."
}