Document r672oopaqmn8gbqeZQgvZKGzq
II EM PLO YER F IL L IN
EXAM INING PHYSICIAN FILL IN
PHYSICAL EXAMINATION
Jofll) P>Uno
Complete this form in triplicate in typewriter and send one copy with X-Ray film to Medical Department, Mutual Insurance Building, 4750 Sheridan Road, Chicago 40, Illinois. The examining phy .'-:an should retain one carbon copy and send the third copy to the employer. The X-Ray film will be returned along with a report.
1 EmployerV.i?.tor Mlg. &_Gasket Co. 57_r.0_W. Roosevelt Rd., Chicago 90, III. _______ ________ ____
2. Employe........--------------------------------------- .Male..X_, Female____ Age-lilt., Single, Married_X-_ 3. Address----------..J?l*.----------------------------------------------- City--QiCBr.Q.----- State..IlI.. Nationality or Race Wh --
4. Job Applied for.........._________________________________Department________ 1-6:________Date Employed_lftsl2sJ
5. Occupational History: (Past Jobs--Naming Employers, Exact Occupations, and Duration) 7/30/1909
Exact Job or
Dates
Employer
Occupation
From
To
Last Job Next Previous Job
Next Previous Job
Next Previous Job
Other
6. Past History: (Diseases, Operations, Disabilities, Amputatipns, etc.)
__________ fhUjL-'A} . McA a/vm - cMAr>rtai> /y
AA4A- L.r. no / AtlLX A.\ ftCz-.<?-A t f~/LF AZm/<?'/?' C Stf- f(J?/. ft n<if Kr>\KrT
il C/A-A, a/m LiflU F,^Sf
7. Present Complaints--------- - --jAlf........................... 21. Lungs
8. Height............... ............
_________ 4-^i
- 22, VqpVose Veins.....
9 Weight.. _
- ..... -
179_________ 23. Hernia............
10. Vision Without Glasses-- R. 20/..42& __L- 20f.
24. Spinal Column
11. Vision With Glasses_____ R. 20/ ,...........T- 20/
25. Sacroiliac*
12. Hearing (Rough Fst.).... ...... /A v fi /Y) . ............ 26. Reflexes.
........
13 Blood Pressure
....................,. .............k........L....................... 77. Extremities..
14. ............ .............. -
2R. Rack ...... ..............
15. Temperature__ 16. Heart (Rate, Abnormal
/Ac A ffl
_________ 29. Sirin_________
...... lOoAtv ..
30. Urinalysis: Sugar.......
Finrtinfr's, **<*.).
Alhnmin,_...,
17 Naal Obstruction ,.........._
....... r.._...... 31. Other Abnormalities,....
18 Teeth
...FzAi'- VjfW' -
19. (tiims............. _
..... ...... .AAr=A~
A ...
70. Throat........ . .. ____ _
____ iL..............1. _
CletR.
T- " r aAM6- t. AAfM
r" r ..... ........ A/t:6r
r/
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........
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:t31. Comments and Recommendations:____ Su-i!
7
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ZA1957-2 6.52 25M
Signed Address_______ Date of Examination.
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1 DANA-051