Document ZBrVY4gw604xab9KGxxpGY79J

* Employe Name (continued)33. X-Ray Identification Number. By Whom Taken?_______________ _____ -- -35. Date Taken------------------------- X-Ray Finding's and Remarks: Silicosis?------ ---------Tuberculosis?--______ Recommendations:___ SignedM.D. Address______________ _______________ Date----------------------------- -------------------------------------------- T)ntr ......................... Date.......................... 0. Special Urine Examinations: (When Indicated or Requested) m. Lead (Milligrams per liter)..... .......... .. .. b Mercury (Milligrams per liter)___________ -- c. Urine Sulfate (Benzol) (%)_______________ d. Other (Specify) ............................ . Date___________________ 1. Wasserman or Kahn_____ ___ ______ _____ _ (When Indicated or Requested) ^^Blood Count: ^^FfWhen Indicated or Requested) a. Red Cells (No.)......... b. White Cells (No.)....................................... c. Hemoglobin ............. _. _ d. Differential Count: ^ Neutrophils (Jn)..................... ........... W Basophils (%) ............ .............. ....... Eosinophils ............... Large Lymphocytes (%)._................... Small Lymphocytes (%).... ....... ....... e. Basophilic Aggregation (%)....... ........ f. Stipple Count (fn)................... ...................... g. Reticulocytes (^>).......................... .............. h. Other Findings____________________________ ' -- I. Sedimentation...................... ............ , (When Indicated or Requested) . Blood Analysis: VPD-1 89-0002451 (When Indicated or Requested) a. Lead (Milligrams per liter)_______________ -- b. Mercury (Milligrams per liter).................... -- c. Other (Specify)___ __ _____________ _ ______ ___ , . ........... t n r 1 ____ i Comments and Recommendations: Signed................ ......... ............. Address............ ........... ............ . Date...........................................