Document wKzM06NEYq4GjB6OKdv6m3V3B

I F-171 RIV. I/M t. UNITED STATES RUBBER COMPANY MEDICAL DEPARTMENT PREPLACEMENT/REEMPLOYMENT HEALTH EVALUATION LAST riSST MI00LE NAME HONE ADDRESS STREET CITY -------- --- SEX fu/ , nation BATE OF SIBTH P3. /S, /933 AGE 3JZ STATE PHONE ' ^ ' `7 NOTI FT IN EMERGENCY ^ - PHONE ,* " FAM1LY PHYS1C1 AN JOB APPLIED FOR: PHONE MARITAL STATUS S (UJ W D SEP OATE OF CXAU. &<l7- /ffS (TO BE FILLED IK BY APPLICANT) The applicant is requested to complete the first two pages of Hits form. Please use care end accuracy in answering the following questions. Hove you ever hod m* of fhe following Illnesses? Cheek ( V) To# or No. If ' Yes Indicate ogewhen condition occurred. _ " 1. Hove you ever lied eny of the following symptoms? Yes * M** .symptom occurred. ** **" when Scarlet Fever Diphtheria Rheumatic Fever Pneumonia Typhoid Fever tnfontile Peralysts Pleurisy Heart Trouble - Asthma Hay Fever or Hives Epilepsy or Fits Malaria Venereal Disease Safeties Arthritis or Rheumatism Allergy Eye Trouble or Injury Defective Vision Sinus Trouble . Frequent Colds Running Ears Defeetive Hearing Frequent Nose Bleeds Chronic Cough Bleed Spitting Chest Pain or Pressure Shortness el Breath High Bleed Pressure Rapid Pulse Paipltatiene Swelling of Ankles Stomach Trouble Vomiting of Bleed Indigestion or Heartburn Bloody or Block Steels Yellow Jaundice Kidney or Bladder Trouble Bleed In Urine Neuritis or Neuralgia Beck Trouble or Lumbago `Trick" or Leaked Knee Frequent or Severe Headaches Nervous Breakdown Difficulty In Sleeping Feinting or Blockout Spoils Numbness and Tingling Loss of Momory Difficulty in Concentrating VCS NO -AGE ej___ CD G2?___ ra mi CD CD ___ C3 O ___ CD 3 ___ CD EJ ___ C3 CD CD CD ___ CD ED ___ CD CD----- rz)---- E( ---a czf -- CD EJ/ -- (3 -- FAMILY HISTORY Please give oge and state of heolth of your mother, father, sisters, brothers, wife and children. If deceased indicate age at -deoth, and cause if known. 33 &ooO 7 &oo& If '43 .aod NCTt*&C. -56 C&oo S'3 Si*r 34 Si TC sis' oc>0 *>o/S c: *r~3 roo $ cn Has anyone in your immediate family (mother, father, sister, brothers, wife, children) ever had any of the following conditions? Chock ( ^ ) Yes or No. If Yos please indicate relative and briefly describe the illness (age at onset, duration, otc.) t CD -NO fV*Tuberculosis CD n/High Blood Pressure CD fV'Heert Trouble ITT' Epilepsy or Fits ref Dfebctes CD ref Hey Fever or Hives CD rST' Migrutne Hoedechos CD refLess of Heering CD l~Pf Mental Disorder CD ny'Timw or Coneor Lt/.Fe /A/ V A/eaf \ MILITARY SERVICE RECORD 1 Hove you ever served in the Armed Forces of the United States? fes rjT'f Ho 2 Which branch? (Jkrmy^Navy, Marines ete.) 2 - Give dates of service. ^^ ^ 4 - Were you ever rejected or discharged by the military service for medical reasons? Yes Q No [Pj If Yes, state reoson. EMPLOYES 1Y 1 one*. Mfit, c.o 0C a ft */& c ~rf<.fpAto^/r A 5 PREVIOUS OCCUPATIONS (List most reeent job first, then next most recent, ete.) Bmu 4C, J9C? /**r A 3W4 /fsv TO 4<t-s9c& a*c **ay /f<r& 5gVCY r' 4.iCj,7~/<*0+V 3hig.T*ktJL Pun? f t \ C /*Zf***tc~ tfePAn?. ?*?<. T/guC/tS Cheek (>/) Yes or No for the following questions. If Yes please give brief explanation, with dates if passible. es wo y I i ED *1 * Hove you ever been hospitalised for any reason?............... .. rzf 2 Have you ever been a patient in a sanitarium or rest home?. |~~1 fT?{ 3 - Have you ever been refused or rated up for Life Insurance? tzf |--1 r^C Q"' 4 * Have you lost time from work due to illness i.n.. the pkwa.s,t 3w yre--ars? _S------ 4flu.r Lr rre *r _____________________________________ 5 * Have you ever received disability payments for any injury or disease?--**0---- P>gr^ggr4 Twu C4/2.S C: X- M- UsC-is<L t tav gg/tVrctS -a Tt*"'/ 6 - Are you sensitive (allergic) to any drugs or medications? fr/3-fO TV r+A*/F T^T SS/uert /'4j?Oit 7 Have you ever hod a persistent or recurrent skin disorder? 7~, ,2r,, i/TfryfffrJ pf I I 8 * Hove you ever had any fractured or broken bones? .* _ny>___________________ ___________ I I I \JT 9 Have you ever been odvised to have a surgical nporatinn? ef 10 - Have you gained or lost more than 10 pounds in the past 3 years?. _ r*- Cj K> O a. WITNESS I hereby declare that the above answers ere true end understand that falsification may be grounds for discharge. r- SICNCD - ATI -- __ _______ " i___________ (NOT TO BE FILLED IN BY APPLICANT) Physician** elaboration and comments on all significant data listod by applicant, (on female applicants - include brief history of catamenia). P I I * PHYSICAL EXAMINATION ,. ' GENERAL APPEARANCE SKIN fU, ERUPTIONS. LKMoRs. SCARS. VtcJ^ aL.-s** IfiL CORNEAE. 4\. COttJUNCTjVAE. rL- 4r PERILS. -<Pl rFuUNMfi. 'etc. r EYES VISUAL ACUITY DISTANT WITHOUT GLASSES ITH GLASSES WITHOUT GLASSES WITH CLASSES --mur-ivt to/*2 0 SO/ EARS RIGHT CANAL 91 OIHJM HEARING *f HIT (VI to/ to/ LEFT CANAL 71 NOSE AND throat MOUTH (INCLUDING TEETH) \ NECK CHEST AND LUNGS It 7t. iwsr. 1" tv.. C&*t, CARDIO VASCULAR SYSTEM PULSE RATE^# v b. p. !**}ro xC/^T ABDOMEN TEMP. HEIGHT IM > x't t /3ti 7\ COLOR PERCEPTION yJ DRUM *fl 73 1SJ O -"sSji ^INGUINAL 'REGION (HERNIA, adenopathy etc.) GENITALIA SPINE 7 ~7&~' -^ANUS AND RECTUM PROSTATE EXTREMITIES NEUROLOGICAL ... s?I Sf n, ADDITIONAL PHYSICAL FINDINGS: ____________ ___________ ________________________ - -. \ LABORATORY DATA FINAL SUM4ARY, COMMENTS AND RECOMMENDATIONS (LISt ALL SIGNIFICANT MEDICAL FINDINGS) z \z Axj CD MEDICAL CLASSIFICATION . <? C D WORK RESTRICTIONS - /TV I hsve discussed the exeainetlon results end the listed recoMsendetlens with the eppticent. OATEt /P-7,2-t- M