Part 45, page 17

Transcript

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

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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16—62265-1 DB Cooper-4640