Part 45, page 18

Transcript

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

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