[Medical Exam for Nathan Billingsley] Page: 2 of 2

                                
51. HEIGHT              52. WEIGHT            53. COLOR HAIR
/9}             170               l

54. COLOR EYES
brn w

55. BUILD:                       56.
SLENDER MEDIUM HEAVY OBESE

57. BLOOD PRESSURE (AArm at heart level)                                  58. PULSE (Arm at heart level)
SIIG sys. 120       REU      sys. --        STNIGsys.       -        SITTING         AFTER EXERCISE  2 MIN. AFTER    RECUMBENT       AFTER ST
DIAS.   82       BENT    DIAS. .        (3 min)  DIAS. -                60            90             60               -                -
59.              DISTANT VISION                   60.                REFRACTION                       61.                 NEAR VISION
RIGHT 20/20            CORR. TO 20/  -            BY     w        S.    -          CX     -            0     0    CORR. TCO/25          BY     --
LEFT 20/ 20            CORR. TO 20/  w            BY     w        S.    -          CX     ./ 0                    CORR. T0 0/20         BY
62. HETEROPHORIA:
(Specify distance)  ES0         EX             R. H.           L. H.           PRISM DIV.          PRISM CONV.            PC            P
63. ACCOMMODATION                      64. COLOR VISION (Test used and result)  65. DEPTH PERCEPTION  UNCORRECTED

RIGHT     .      LEFT

Sa c CORRECTED

66. FIELD OF VISION

67. NIGHT VISION (Test used and score)

68. RED LENS

69. INTRAOCULAR TENSION

10.         HEARING             71.                       AUDIOMETER
250    500    1000   2000   3000   4000    8000
RIGHT WV       /15 SV      /15           2156   512    1024   2048   2896   4096   8192
RGRIGHT WV                                            .        .    w
LEFT WV        /15 SV1 I   /15
LEFT             -     -                    -

73. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY
mps    4: :1   questionable           whL0 c
To Isi11ectony, 1940.                     o comp, o se.
196        0               jo  s   r

7. PSYCHOLOGICAL AND PSYCHOMOTOR (T.

-' CO K.

(tie culditiosmul sheets of plii paper if naecess-sry)
4.30  353O~)FFOTO:0  Oe~'IEE  (K . ~weeei4% i('3; 'a  erS

75. RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

76.        PHYSICAL PROFILE
P     U      L     H     E     S

77. EXAMINEE (Check)
IS    Q        FOR                                                                                                     PHYSICAL CATEGORY
IS NOT QUALIFIED FORy
78. IF NOT QUALIFIED. LIST DISQUALIFYING DEFECTS BY ITEM NUMBER                                                       A          B          C         E
79. TYPED OR PRINTED NAME OF PHYSICIAN                                              T
E     J              CV.            ) F__C__

80. TYPED OR PRINTED NAME OF PHYSICIAN
SO. ' PED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)

SIGNATURE

(I/

SIGNATURE

?. PRINTED NAME OF REVIEWING OF  CEP OR APPROVING AUTHORITY    SIGNATURE
-              0-                      ' fufMK;        (

NUMBER OF AT-
TACHED SHEETS

TEMP.
98,

-

I (zest used and score)

..                           .

'i

a en ldhood.

see .