Document 9n2pGdDYZ5RenRKK8J40O3o5

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................... ........... Date................................. 0. Special Urine Examinations: (When Indicated or Requested) a. Lead (Milligrams per liter).......................... It. Mercury (Milligrams per liter)................... c. Urine Sulfate (Benzol) (%)......................... d. Other (Specify).............................................. 1. Wasserman or Kahn......................................... (When Indicated or Requested) Blood Count: (When Indicated or Requested) a. Red Cells (No.)...................... 0. White Cells (No.)............ c. Hemoglobin (%)............... . ... d. Differential Count: ^ Neutrophils (%)......... . Basophils (%)............... .. Eosinophils (%)............... Large Lymphocytes (%)--'................. Small Lymphocytes (%).............. e. Basophilic Aggregation (%)..................... f. Stipple Count (%)............................... g. R-et-icu-locytes .......... h. Other Findings................................... ' L Sedimentation........................... (When Indicated or Requested) 1. Blood Analysis: (When Indicated or Requested) a. Lead (Milligrams per liter)............... h. Mercury (Milligrams per liter)......... c. Other (Specify)................. VPD-1 89-0002447 Comments and Recommendations: Signed... Address 1 >ate.......