Report of Medical Examination (SF-88) on separation - 1st Lt John E. List, Camp Stoneman
Document date 21 April 1952
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Id: Cooper-Part-45:017-018
Subject: Cooper Files: Cooper-Part-45:017-018 Document: Report of Medical Examination (SF-88) on separation - 1st Lt John E. List, Camp Stoneman Id: Cooper-Part-45:017-018 Page: https://cooper.theunsolved.net/documents/Cooper-Part-45%3A017-018 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
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FBI 164-81, Vault Part 45 pp. 17–18 (DB Cooper-4640–4641), Form, dated 21 Apr 1952, serial 16-52283-1 (as read from the transcript) — cooper.theunsolved.net/documents/Cooper-Part-45%3A017-018
Standard Form 88 (Revised: 1950) PROMULGATED BY BUREAU OF THE BUDGET CIRCULAR A-24
REPORT OF MEDICAL EXAMINATION
1. LAST NAME—FIRST NAME—MIDDLE NAME: LIST, JOHN E. 2. GRADE AND COMPONENT OR POSITION: 1st LT. TC 3. IDENTIFICATION NO.: 0-978253 4. HOME ADDRESS (Number, street or RFD, city or town, zone and State): 463 PRINCETON, SAN FRANCISCO, CALIF. 5. PURPOSE OF EXAMINATION: SEPARATION 6. DATE OF EXAMINATION: 21 APRIL 52 7. SEX: M 8. RACE: W 9. TOTAL YRS. GOVT. SERVICE: [blank] MILITARY / CIVILIAN 10. DEPARTMENT, AGENCY, OR SERVICE: ARMY 11. ORGANIZATION UNIT: 6213 ASU 12. DATE OF BIRTH: [blank] 13. PLACE OF BIRTH: [blank] 14. NAME, RELATIONSHIP, AND ADDRESS OF NEXT OF KIN: MRS JOHN E. LIST, 463 PRINCETON, SAN FRANCISCO, CALIF. 15. EXAMINING FACILITY OR EXAMINER, AND ADDRESS: CAMP STONEMAN, CALIFORNIA 16. OTHER INFORMATION: [blank] 17. RATING OR SPECIALTY: [blank] TIME IN THIS CAPACITY: TOTAL [blank] LAST SIX MONTHS [blank]
CLINICAL EVALUATION (Check each item in appropriate column; enter "N E" if not evaluated)
18. HEAD, FACE, NECK, AND SCALP - NORMAL #39 SCAR, RIGHT MASTOID, EPTS: 19. NOSE - X [abnormal] 20. SINUSES - X [abnormal] 21. MOUTH AND THROAT - X [abnormal] 22. EARS—GENERAL (Int. & ext. canals) (Auditory acuity under items 70 and 71) - X 23. DRUMS (Perforation) - X b6 per NPRC b7C 24. EYES—GENERAL (Visual acuity and refraction under items 59, 60, and 61) - X 25. OPHTHALMOSCOPIC - X 26. PUPILS (Equality and reaction) - X 27. OCULAR MOTILITY (Associated parallel movements = nystagmus) - X 28. LUNGS AND CHEST (Include breasts) - X 29. HEART (Thrust, size, rhythm, sounds) - X 30. VASCULAR SYSTEM (Varicosities, etc.) - X 31. ABDOMEN AND VISCERA (Include hernia) - X 32. ANUS AND RECTUM (Hemorrhoids, fistulae) (Prostate if indicated) - X 33. ENDOCRINE SYSTEM - X 34. G-U SYSTEM - X 35. UPPER EXTREMITIES (Strength, range of motion) - X 36. FEET - X 37. LOWER EXTREMITIES (Except feet) (Strength, range of motion) - X 38. SPINE, OTHER MUSCULOSKELETAL - X 39. IDENTIFYING BODY MARKS, SCARS, TATTOOS - X 40. SKIN, LYMPHATICS - X 41. NEUROLOGIC (Equilibrium tests under item 72) - X 42. PSYCHIATRIC (Specify any personality deviation) - X
Females only (Check how done) 43. PELVIC [ ] VAGINAL [ ] RECTAL (Continue in Item 73)
44. DENTAL (Place appropriate symbols above or below number of upper and lower teeth, respectively) O—Restorable teeth X—Missing teeth (& X &)—Fixed bridge, brackets to include abutments L—Non restorable teeth XXX—Replaced by dentures
R: X 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 X5 L E F L: X 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 X/ Y
CLASS I
LABORATORY FINDINGS 45. URINALYSIS: SP. GR.: 1.026 ALBUMIN: NEG SUGAR: NEG MICROSCOPIC: NOT DONE 48. LKG: [illegible] 49. BLOOD TYPE AND RH FACTOR: O
46. CHEST X-RAY (Place, date, film number, result): 258 NEG
47. SEROLOGY (Specify test used and result): CARDIOLIPIN#NEG.
50. OTHER TESTS: NONE
NOT DONE
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CAUTION: SPECIAL HANDLING REQUIRED This material copied from records of National Personnel Records Center, St. Louis, Missouri, to be used for reference only. Do not recopy or disseminate in its original form outside the Bureau.
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[illegible] /[guess: p]-[guess: v] r-[illegible]
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16—62265-1 DB Cooper-4640
MEASUREMENTS AND OTHER FINDINGS
51. HEIGHT: 73 1/[illegible] 52. WEIGHT: 180 53. COLOR HAIR: BROWN 54. COLOR EYES: BROWN 55. BUILD: SLENDER MEDIUM HEAVY OBESE [X] (Medium checked) 56. TEMP.: NORMAL
57. BLOOD PRESSURE (Arm at heart level) SITTING: SYS. 132 / DIAS. 60 RECUMBENT: SYS. [blank] / DIAS. [blank] STANDING (3 mins.): SYS. [blank] / DIAS. [blank]
58. PULSE (Arm at heart level) SITTING: 80 AFTER EXERCISE: 100 2 MIN. AFTER: 80 RECUMBENT: [illegible] AFTER STANDING 3 MIN: [blank]
59. DISTANT VISION RIGHT 20/ 200 CORR. TO 20/ 20 LEFT 20/ 200 CORR. TO 20/ 20
60. REFRACTION BY S. CX [blank] BY S. CX [blank]
61. NEAR VISION CORR. TO BY CORR. TO BY
62. HETEROPHORIA (Specify distance): ES* EX' R. H. L. H. PRISM DIV. PRISM CONV PC PD
63. ACCOMMODATION RIGHT LEFT
64. COLOR VISION (Test used and result): [blank]
65. DEPTH PERCEPTION (Test used and score): UNCORRECTED / CORRECTED [blank]
66. FIELD OF VISION
67. NIGHT VISION (Test used and score)
68. RED LENS
69. INTRAOCULAR TENSION
70. HEARING RIGHT WV: 15 /15 SV: 15 /15 LEFT WV: 15 /15 SV: 15 /15
71. AUDIOMETER 250 500 1000 2000 3000 4000 8000 RIGHT [blank] [illegible values] LEFT [shaded/hatched region]
72. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score): [blank]
73. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY: [blank]
(Use additional sheets of plain paper if necessary)
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74. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers): [blank]
75. RECOMMENDATIONS--FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify): [blank]
76. PHYSICAL PROFILE P U L H E S 1 1 1 1 2 1
PHYSICAL CATEGORY A B C E X
77. EXAMINEE (Check) [X] IS QUALIFIED FOR [ ] IS NOT SEPERATION
78. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER: [blank]
79. TYPED OR PRINTED NAME OF PHYSICIAN: t/E. FONG IST LT. MC SIGNATURE: s/ E. FONG
80. TYPED OR PRINTED NAME OF PHYSICIAN: t/E. PEKELIS, M.D. SIGNATURE: s/ E. PEKELIS
81. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which): [blank] SIGNATURE: A TRUE COPY;
82. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE: FRANK P. BOMMARITO, 2nd LT. M.S.[C] NUMBER OF AT[TACHED] SHEETS: [blank]
U. S. GOVERNMENT PRINTING OFFICE 16-52283-1
DB Cooper-4641
Serials: 0-978253, 16-52283-1, 16—62265-1