Document NN1EVkzYpBDMeJGENLr7xLaw

.A / Et h y l Ga s o l in e Co r p o r a t io n HISTORY SHEET Case No............................. Name Birthplace jo r......................... Cj^arrieX)---- ,-- Single Living with Wife Date # ....... .... Age...__ Children..^. Trade..../^-- Lead Exposure ....fc;.... illnesses (Injuries and Operations)........ Suggestive History of Syphilis, Tuberculosis, Heart Disease, Nephritis, Malaria, Alcoholism, Epilepsy, Insanity, ...-. ^ '____ ...................... ......... jsgiuiicant familvliistpry (Nervous conditions and insanity)............. .:.....-...............:............ ..................... Genera! Health .................................................... ..............:...r................. Usual Weight Habits of ^ A/ . Appetife^^ltI?J^._rr_...................... Constipation...^^AOC?............................... Indigestion ' J't &~Z<J2 '........... --/fs Periodic Headache----- Other symptoms now present........................................*........ .......................... Sexual History_____....__________ Et h y l Ga s o l in e Co r p o r a t io n PHYSICAL EXAMINATION Case No., ____,,........ Name....T n,i.' ' --................. --- Date Height..... .................................. Weight [stripped)........ ..............................--............... Temperature.....,?*?;..?...... General Appearance ...... .--.........-............................................................................................ Nutrition Developmer Skin Nose _ Posture Jr> WiXn ............ sa*c^3^--.^..-. .<2Ui4^ <- /C^ofSmell Ear Mouth /n ......... ....................... Throat Lymph Glands .7^Cddjdr^ Chest--Respiration.........../f".................... . Pulse....... ...'...................... Blood Pressure a S-'Q. k'S Chest Measurements at Nipple Line....... .......... .................................... Heart Measurements ,y^?'.-<p.../^2fc--^ a e. 3-^ *<_. <2^-.^J-. K-x (Li s 'O ^ - 3" / 0QM&d>s AW,TM Pelvis Extre ...................................................... ............................................................ .................. .... ... ....I. Central Nervous System--[Reflexes, signs, tremors, sensation) .... ^________________________ * Muscular Strength--Right Hand..... ..--............v_......... ............... Left Hand......... .... v5'`v I HEREBY ACKNOWLEDGE THAT I HAVE BEEN ADVISED BY.---------- ......._________________________________ ___ _______ REPRESENTING THE ETHYL GASOLINE CORPORATION. THAT ETHYL FLUID IS A POISON AND FURTHER THAT I HAVE RECEIVED FROM HIM INSTRUCTIONS AND INFORMATION RELATIVE TO THE DANGERS AND RISKS ASSOCIATED WITH THE HANDLING OF SAID FLUID. '.rC:?-- Witness: Employee. KE 0016578 :: . Cs:.: sifiSfeiSj Et h y l Ga s o l in e Co r p o r a t io n NOTES ON CASE Gas No.------------------------ ZzM-zM- Name ' at ^ J*&Lj L!L2z&^ ^ ' V'S& <s^yd , ___ _7__ KE 0016579 YS^Kifi___ i^2k&!3Z&. .- ; Ga s o l in e Co r p o r a t io n /P /c NOTES ON CASE V ;.?V ------- --------- V ' < , ' ' . A".-o'' HE0016580