Document 7MwKv47Em4LRv68X4YpNVQ0YR
Employe Name (continued)._ By Whom Taken?..................... X-Ray Findings and Remarks
..33. X-Ray Identification Number.......... .......................... .............. -35. Date Taken--------------------------------------------- ------- -----------------
. Silicosis ?.... ........... . Tuberculosis?------. Recommendations
Signed.___________ __________________________________ M.D. Address
Date__________________ _ Date. - . ...
Date____________________
0. Special Urine Examinations: (When Indicated or Requested)
a. Lead (Milligrams per liter). .............. .....
b. Mercury (Milligrams per liter)___________ ........ ............... ............. --. .......--.......... ..... .... ........... c. Urine Sulfate (Benzol) (%).......... .. ........
d. Other (Specify)-........................................ ...
---------- --------------------------
1. Wasserman or Kahn___ _____________________ (Whtn Indicated or Requested)
Blood Count: (When Indicated or Requested)
a. Red Cells (No.)--_____ _______________ __ *---- ------------- ----*---------b. White Cells (No.).............. -..........................
--.... ....... ---.......... ....... ......
c. Hemoglobin (%)...........................................
d. Differential Count:
^ Neutrophils (fo)~.................................. ------------------------------------
Basophils- (fo).... ......... ......... ............. ....
Eosinophils
....... .......................... ......
Large Lymphocytes (%).......... ..... .....
Small Lymphocytes (%)--------------------t. Basophilic Aggregation {%)............. ..........
.. ........... .......... .
.... ..... --..... ......... ..
f. Stipple Count (%)......................................... g. Reticulocytes (fo)_______________________
--....................................
h. Other Findings
3. Sedimentation.................. ...................................
(When Indicated or Requested)
4. Blood Analysis:
(When Indicated or Requested)
a. Lead (Milligrams per liter).... ................... .. b. Mercury (Milligrams per liter).................... c. Other (Specify)________________ ________
VPD-18 9-0002455
Comments and Recommendations