Part 114, page 404

Transcript

The scan is the source; the transcript is machine-generated from it.

ARMED FORCES MODIFICATION Standard Form 88 PROMULGATED MARCH 1948 BY BUREAU OF THE BUDGET CIRCULAR A-21

REPORT OF MEDICAL EXAMINATION

INSTRUCTIONS FOR PREPARING THIS FORM.—N. S. A. represents No Significant Abnormality. In Items No. 20 through No. 41, if abnormal, describe in space of each heading, or under No. 42, "Remarks," or if necessary on additional sheets the same size. Write on each sheet name, date of birth, and identification number.

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1. LAST NAME—FIRST NAME—MIDDLE NAME MILES SCHUYLER W. JR.

2. PLACE AND DATE OF EXAMINATION FOSH 8th, MAR 1950

3. DATE OF BIRTH: 30 JUNE 23 4. AGE IN YEARS LAST BIRTHDAY: 27

5. IDENTIFICATION NO.: 0 493 718

6. PURPOSE OF EXAMINATION RELIEF FROM ACTIVE DUTY

7. SERVICE, DEPARTMENT, OR AGENCY INF.RES.

8. COMPONENT AND BRANCH: [partially illegible]

9. ORGANIZATION: [redacted/XXX]

10. GRADE, RATING, OR POSITION: CAPT.

11. SEX: MAle 12. RACE: WHITE

13. HOME ADDRESS (Street, or RFD number, city, zone, State) 1423 COVINA AVE, LONG BEACH CALIFORNIA

14. PLACE OF BIRTH: WASHINGTON PA.

15. OTHER DATA / SELECTIVE SERVICE NO.: [blank]

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16. RATING OR SPECIALTY: [blank]

17. MEASUREMENTS: HEIGHT (shoeless): 68 INS. WEIGHT (stripped): 140 LBS. 18. BUILD: [X] MEDIUM/SLENDER 19. TEMP: 98.6

20. SKIN—INCLUDING HAIR DISTRIBUTION, THICKNESS OF NAILS, TATTOOING, AND SCARS N. S. A. [X]

21. LYMPH GLANDS AND LYMPHATICS: N.S. A. [X]

22. HEAD, FACE, AND NECK—N. S. A. [X]

23. NOSE, SINUSES, MOUTH, AND THROAT—N. S. A. [X]

24. EARS—A. CANALS, EXT. EARS—N. S. A. [X]

C. HEARING (Whispered and spoken voice at 16 ft.) RIGHT WV 15 /15: SV 15 /15 LEFT WV 15 /15: SV 15 /15

D. AUDIOMETER DECIBELS LOSS: [blank]

B. DRUMS—NO PERFORATION [X] N.S.A. [X]

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25. EYES—A. EXTERNAL EYE, RIGHT EYE—N.S.A. [X] LEFT EYE—N.S.A. [X] B. PUPILS—EQUAL [X] NORMAL TO ACCOMMODATION [X] TO LIGHT [X] C. ASSOCIATED PARALLEL MOVEMENTS, NYSTAGMUS—N. S. A. [X] D. DISTANT VISION E. REFRACTION (Manifest) (Cycloplegic) STRIKE OUT ONE RIGHT 20/20 CORR. TO 20/ BY S.C LEFT 20/20 CORR. TO 20/ BY S.C F. NEAR VISION—(At 14 inches): CORR. TO [illegible] G. COLOR VISION—N. S. A. [X] TEST USED H. HETEROPHORIA (Specify distance): ESO EXO R. H. L. H.

I. RED LENS—N. S. A. [X] J. FIELD OF VISION—RIGHT—N. S. A. [X] LEFT—N. S. A. [X] K. DEPTH PERCEPTION [partially illegible] L. OPHTHALMOSCOPIC—RIGHT—N.S.A. [partially illegible] M. ACCOMMODATION—RIGHT [partially illegible] LEFT [partially illegible] LEFT—N. S. A. [X]

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26. DENTAL—INDICATE FINDINGS BY PLACING SYMBOL ON TOOTH NUMBER: RESTORABLE CARIOUS TEETH, O; EXTRACTION REQUIRED, [X]; MISSING NATURAL TEETH, X; FULL OR PARTIAL DENTURE (LINE OVER NUMBER OF TEETH INVOLVED, X'ING OUT [partially illegible]) TEETH, [partially illegible]; FIXED BRIDGE (LINE UNDER NUMBERS OF TEETH INVOLVED, X'ING OUT REPLACED NATURAL TEETH, BRACKETS TO INCLUDE BRIDGE ABUTMENT, (I.X.)); CROWNS, C; IMPACTED TEETH, #; FILLINGS PRESENT, F; NORMAL TEETH, N; DECIDUOUS TEETH [partially illegible]

UR: [tooth chart - upper right] 1 2 3 4 5 6 7 8 X O X X O X N N

9 10 11 12 13 14 15 16 N N N F X F N X

LR: 32 31 30 29 28 27 26 25 F X F F N N N N

24 23 22 21 20 19 18 17 N N 0 F X F O X

CLASS: II. MALOCCLUSION—N. S. A. [X] PERIODONTOCLASIA—N. S. A. [X] GINGIVITIS—N. S.A. [partially illegible] REMARKS AND DISQUALIFYING DENTAL DEFECTS: [partially illegible]

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27. PULSE RATE AND BLOOD PRESSURE (Arm at heart level) SITTING: PULSE [blank] B. P.: S. 106 D. 64 STANDING (3 min.): PULSE [blank] B. P.: S. [blank] D. [blank] RECUMBENT: PULSE [blank] B. P.: S. [blank] D. [blank] SITTING/PULSE AFTER EXERCISE: [blank] 12 MIN. AFTER [blank]

28. LUNGS—N. S. A. [X] CHEST—N. S. A. [X] 29. CHEST—N. S. A. [X] NOT DONE [blank] (Include [guess: frontal]) X-RAY [partially illegible]

30. HEART—N. S. A. [X] 31. EKG—N. S. A. [blank] NOT DONE [X]

32. VASCULAR SYSTEM—A. ARTERIES AND VEINS—N. S. A. [X] B. VARICOSE VEINS—NONE [X]

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DB COOPER-52446