Document qkgO14aEj0e7DmLG5Yow002vk

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'I PiU- sr // . w. doa Physt cal on Pnncrt ' /- V- 73 --"7 Av 4v0**0<L J a-.t- Tir.iP *r.-i c'r P .in-jp jLco'o.. j // iZ^'r/Lab fork (CUC, Urina3 ysi b)C/^'U j^f^x.ray (PA Chest Only) ; , i'W <^^, -Ckc :amT' ioan tin yim wnTviHk /'J/Jj*/{ f ^t. ^Physical Kxan & Ilictory 'A^ . . /. .4 * ~ ;'fi,^/-f ? Audic__m___'._'_t__r_ ci_c r**i*l*\ v!iV ..'/* ^Forced Vital Capacity tj-Z. ' (>7; x /T* / ^V^Forccd Expiratory Volume at 1 see. ^ . ,-______ _____ io.irrg'^i,eem.*'ri.||i)`Yeuir* t * / (to at iitKta i prcscncc or pcASOHNCk M*kci /y ^K!i;;.Nr>.UAUAi(ii \ -EMPLOYMENT (m; f ., Suct:c;< a rrfc'at comfuctco ay nuns* on physician ako sigkco y cxamikcci Q FIRST | 1 PERIODIC MANITAA. STATUS M ,W D chilonch L0 ["I Recall AACVIOWS OCCUPATION s3d4rfXte*t<*Jt I iSUBSEQUENT BLOCO TYPC Ik 1! sf. ,A r 1 .AIkT ON INTCAVAk. HISTORY, 1 uY HISTORY & ANO HCALTH ON, IP OCAO fATMEH & H*4/t or: at-ano cause qcath. mother, f-+tif 3J*~- ___ t. - . past history - chcck I I if positivc oa hcoat.vt. ir .aiinrc *<'. r:t* of cccyaexci: an CXAIAIH ettov. . -Yl' ^ ".' t A - -1 ' V - - '; A ' \ : it CA QAOkCHiT_lA Itb; no M emtAsr 7T TYAHOIO rtV <yis; ko STAllltlS COMOitAMCA !yw. ~| j/\ evrn u AJivATt cC.A TUOklC ks:a o ~T IA, imstit. yon mint: OI3A*IUTr"', 'cuiasis OLOOOY UAIkC _jj 1/|hC:iIA OH NUHTUNC ANY MUITAH- HICOICAk ON X . ,H ITVS ILNT COCOS AOkUkC "C os o/siKTerr cres -*me; inusi TINS .istaht ecus* ere CONDITIONS W KIN_C_Q__N_3__IT_INKS IXOICCSTION IT KIOhCY TNSUOkC hCaNTtnowwlc NCNYOWS SNCAKONWh OACAACHC T amcumatic rtvcN l ir i(mu* rrn* ANTHAlTlS j i/] A.neost vriks j_ ^j/' MCHII.ilTIS , l/1 00 YOU ">.A CCACSeS t cv-ct q:& i.ijwo . ! even *M eve UUU4T ViHe even fCrn r.^rTUAC I ! cvc mf.1T tgu? UnCK ia cv*. ovc*;c qm tYCA acccive comp, yon TV AN ilUUNf JUNCICAk CONDITION ( "** ** TiT-'y ocrar.unita i \IS \ y oisaoiutt fi-jiON oa ihsuAAkcc oeNcriT* roa illnisi1, ON* INJU.TY jii. 3 CiFlC REFFSHNCE TO 3ACC CONDITION: I certify jhat I hove not had a..*:*: lanations: .`o' uniio.oi.es, .?tc. ) jU^X (, yrtnuU., > / 9Sf JPT**^** ,*s* <*~**A* ftjH & :' V"Xv A242 1 4 X4 1 V nilv fJ'Vt my wAbr ia of tr m*>i >ty ni^ i trml rwiiuA ith*y< Mile* ith9riie v !* tef ifteccutv'e. nIt. , v ' ^ Vt i;., . oT'iaM r rAeriicVk-Y'. 'i'-'ir1 * t * ** - ;. \ " , ; ^.TV- i-, ' * ; r''t < ;* "*;vf * * T . "'' >3;,jf y*. 'r*-f** -Mien, if thn cc^puny .^V^VSS'VV'- I.-- ::;:'! (wh* {fa*d***^*r / ; :/ Mn WITH | v | If (1,11 0T AMO oiacmac allow want* rtaomtl. <* -- fJ ;r. 1 w Mogta , Tccr* , c- TOM3U >--iAt oil LIMAN lOKCS -AIMIA U C- A*CilfLIA -*UX yahko*tic* AAC j - TnYHIO CiTnewlT ICt (*n% \, tNaA, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ L-: .* * vre yoj vking any medication; dt the present time/ -- 5t,sieving SCAM OR OCriCTS! c- ,n*r -AtVlAO CXAM. J-d Are you under the cr of < doctor at present? .. 1 . t ! c c-- ( 4 HECK ONE 1. Fit for >11 types of work Q* 2. Fit, for specific job or position Q Rejection IF YOU HAVE CHECKED ITEM TWO OR THREE ABOVE OESCRIBE UMITATIONS OR REASON FOR REJECTION*. . sets.-