SF_88.pdf

PDF 555 KB Posted May 29, 2025

Attached to: Medical Surveillance
Solicitation number: FA670325Q0006
Issued by: Department of the Air Force Reserve Command

About this file

Written by GovTribe AI · May 29, 2025

This document is a Standard Form 88 (SF-88) Medical Record Report of Medical Examination, a comprehensive medical evaluation form used for documenting an individual's detailed health assessment. The form captures extensive medical information including clinical evaluations across multiple body systems, dental status, vision and hearing tests, measurements, vital signs, and overall physical profile. Sections include clinical evaluations of head, face, neck, ears, eyes, respiratory, cardiovascular, neurological, and other physiological systems, along with specific diagnostic test results such as urinalysis, chest x-ray, EKG, and blood work.

The form is structured to provide a comprehensive medical overview, with spaces to record normal and abnormal findings, diagnostic test results, recommendations for further specialist examinations, and ultimately determine the individual's physical qualification status. Key sections include detailed assessments of vision (distant and near), hearing, color vision, depth perception, psychological and psychomotor evaluations, and a summary of any identified defects or diagnoses. The form is designed to thoroughly document an individual's medical condition and fitness for a specific role or position, with spaces for physician signatures, reviewing officer approval, and a final determination of medical qualification.

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1. LAST NAME - FIRST NAME - MIDDLE

MEDICAL RECORD REPORT OF MEDICAL EXAMINATION

DATE OF EXAM

2. IDENTIFICATION NUMBER 3. GRADE AND COMPONENT OR POSITION

4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code) 5. EMERGENCY CONTACT (Name and address of contact)

6. DATE OF BIRTH 7. AGE 8. SEX 9. RELATIONSHIP OF CONTACT

10. PLACE OF BIRTH 11. RACE

12a. AGENCY 12b. ORGANIZATION UNIT 13. TOTAL YEARS GOVERNMENT SERVICE

a. MILITARY b. CIVILIAN

14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS 15. RATING OR SPECIALTY OF EXAMINER

16. PURPOSE OF EXAMINATION

17. CLINICAL EVALUATION

NOR-

MAL

ABNOR-

MAL

NOR-

MAL(Check each item in appropriate column, enter "NE" if not evaluated)

A. HEAD, FACE, NECK AND SCALP

(Check each item in appropriate column, enter "NE" if not evaluated)

B. EARS - GENERAL (INTERNAL CANALS)

(Auditory acuity under items 39 and 40)

C. DRUMS (Perforation)

D. NOSE

E. SINUSES

F. MOUTH AND THROAT

G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and 36)

H. OPHTHALMOSCOPIC

I. PUPILS (Equality and reaction) J. OCULAR MOTILITY (Associated parallel movements nystagmus)

K. LUNGS AND CHEST

L. HEART (Thrust, size, rhythm, sounds) M. VASCULAR SYSTEM (Varicosities, etc.)

N. ABDOMEN AND VISCERA (Include hemia)

O. PROSTATE (Over 40 or clinically indicated)

P. TESTICULAR

Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)

R. ENDOCRINE SYSTEM

S. G-U SYSTEM

T. UPPER EXTREMITIES (Except feet) (Strength, range of motion)

U. FEET

V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

W. SPINE, OTHER MUSCULOSKELETAL

X. IDENTIFYING BODY MARKS, SCARS,TATTOOS

Y. SKIN, LYMPHATICS

Z. NEUROLOGIC (Equilibrium tests under item 41) AA. PSYCHIATRIC (Specify any personality deviation)

BB. BREASTS

CC. PELVIC (Females only)

NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary)

REMARKS AND ADDITIONAL DENTAL

DEFECTS AND DISEASES

A. URINALYSIS: (1) SPECIFIC GRAVITY

(2) URINE ALBUMIN

(3) URINE SUGAR

C. SYPHILIS SEROLOGY (Specify test used and results)

(4) MICROSCOPIC

D. EKG E. BLOOD TYPE AND HR

FACTOR

B. CHEST X-RAY OR PPD (Place, date, film number and result)

NSN 7540-00-634-6038

88-126 Designed using Perform Pro, WHS/DIOR, Jan 97

STANDARD FORM 88 (Rev. 10-94) (EG) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

18. DENTAL (Place appropriate symbols, show in examples, above or below number of upper and lower teeth.)

1 2 3 32 31 30

Restorable Teeth

Non-restorable

Teeth

Missing Teeth

Replaced by

Dentures

Fixed Partial

Dentures

( X ) 1 2 3

32 31 30 ( X )

1 2 3

32 31 30

X 1 2 3

32 31 30 X

X X X 1 2 3

32 31 30 X X X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

R I G H T

L E F T

ABNOR-

MAL

FEMALE MALE

WHITE BLACK

AMERICAN INDIAN/

ALASKA NATIVE

HISPANIC

WHITE

HISPANIC

BLACK

ASIAN/PACIFIC

ISLANDER

F. OTHER TESTS

19. TEST RESULTS (Copies of results are preferred as attachments)

NAME IDENTIFICATION NO. OF SHEETS ATTACHED

MEASUREMENTS AND OTHER FINDINGS

20. HEIGHT 21. WEIGHT 22. COLOR HAIR 23. COLOR EYES 24. BUILD 25. TEMPERATURE

26. BLOOD PRESSURE (Arm at heart level)

SITTING

SYS.

DIAS. DIAS.

SYS.

DIAS.

SYS.B.

RECUM-

BENT

STANDING

(5 MINS.)

27. PULSE (Arm at heart level) A. SITTING B. RECUMBENT C. STANDING (3mins.) D. AFTER EXERCISE E. 2 MINS. AFTER

28. DISTANT VISION

RIGHT 20/

LEFT 20/

CORR. TO 20/

29.REFRACTION

30. NEAR VISION

CORR. TO

31. HETEROPHORIA (Specify distance)

ESO EXO R.H. L.H. PRISM DIV. PRISM CONV.

CT PC PD

32. ACCOMMODATION

RIGHT

LEFT

35. FIELD OF VISION

39. HEARING

33. COLOR VISION (Test used and result)

36. NIGHT VISION (Test used and result)

34. DEPTH PERCEPTION

(Test used and score)

37. RED LENS TEST

UNCORRECTED

CORRECTED

38. INTRAOCULAR TENSION

RIGHT LEFT

RIGHT W/V

LEFT W/V

/15SV

/15

40. AUDIOMETER

RIGHT

LEFT

41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)

42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY

43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) 45A. PHYSICAL PROFILE

P U L H E S

A B C E

45B. PHYSICAL CATEGORY

46. EXAMINEE (Check)

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER

48. TYPED OR PRINTED NAME OF PHYSICIAN

49. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)

51 TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY

IS QUALIFIED FOR

IS NOT QUALIFIED FOR

STANDARD FORM 88 (REV. 10-94)

SLENDER MEDIUM HEAVY OBESE

(Use additional sheets if necessary)

1. LAST NAME - FIRST NAME - MIDDLE NAME

MEDICAL RECORD

REPORT OF MEDICAL EXAMINATION

DATE OF EXAM

2. IDENTIFICATION NUMBER

3. GRADE AND COMPONENT OR POSITION

4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code)

5. EMERGENCY CONTACT (Name and address of contact)

6. DATE OF BIRTH

7. AGE

8. SEX

9. RELATIONSHIP OF CONTACT

10. PLACE OF BIRTH

11. RACE

12a. AGENCY 12b. ORGANIZATION UNIT

13. TOTAL YEARS GOVERNMENT SERVICE

a. MILITARY

b. CIVILIAN

14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS

15. RATING OR SPECIALTY OF EXAMINER

16. PURPOSE OF EXAMINATION

17. CLINICAL EVALUATION

NOR-MAL

ABNOR- MAL

NOR-MAL

(Check each item in appropriate column, enter "NE" if not evaluated)

A. HEAD, FACE, NECK AND SCALP

(Check each item in appropriate column, enter "NE" if not evaluated)

B. EARS - GENERAL (INTERNAL CANALS)

(Auditory acuity under items 39 and 40) C. DRUMS (Perforation)

D. NOSE

E. SINUSES

F. MOUTH AND THROAT

G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and 36)

H. OPHTHALMOSCOPIC

I. PUPILS (Equality and reaction) J. OCULAR MOTILITY (Associated parallel movements nystagmus)

K. LUNGS AND CHEST

L. HEART (Thrust, size, rhythm, sounds) M. VASCULAR SYSTEM (Varicosities, etc.)

N. ABDOMEN AND VISCERA (Include hemia) O. PROSTATE (Over 40 or clinically indicated)

P. TESTICULAR

Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results)

R. ENDOCRINE SYSTEM

S. G-U SYSTEM

T. UPPER EXTREMITIES (Except feet) (Strength, range of motion)

U. FEET

V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

W. SPINE, OTHER MUSCULOSKELETAL

X. IDENTIFYING BODY MARKS, SCARS,TATTOOS

Y. SKIN, LYMPHATICS

Z. NEUROLOGIC (Equilibrium tests under item 41) AA. PSYCHIATRIC (Specify any personality deviation)

BB. BREASTS

CC. PELVIC (Females only) NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary)

REMARKS AND ADDITIONAL DENTAL DEFECTS AND DISEASES

A. URINALYSIS: (1) SPECIFIC GRAVITY

(2) URINE ALBUMIN

(3) URINE SUGAR

C. SYPHILIS SEROLOGY (Specify test used and results)

(4) MICROSCOPIC

D. EKG

E. BLOOD TYPE AND HR

FACTOR

B. CHEST X-RAY OR PPD (Place, date, film number and result)

NSN 7540-00-634-6038

88-126 Designed using Perform Pro, WHS/DIOR, Jan 97 STANDARD FORM 88 (Rev. 10-94) (EG) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

18. DENTAL (Place appropriate symbols, show in examples, above or below number of upper and lower teeth.)

1 2 3 32 31 30 Restorable Teeth Non- restorable Teeth Missing Teeth Replaced by Dentures Fixed Partial Dentures ( X ) 1 2 3 32 31 30 ( X ) 1 2 3 32 31 30 X 1 2 3 32 31 30 X X X X 1 2 3 32 31 30 X X X 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 R I G H T L E F T

ABNOR- MAL

FEMALE

MALE

WHITE

BLACK

AMERICAN INDIAN/ ALASKA NATIVE

HISPANIC WHITE

HISPANIC BLACK

ASIAN/PACIFIC ISLANDER

F. OTHER TESTS

19. TEST RESULTS (Copies of results are preferred as attachments)

NAME

IDENTIFICATION

NO. OF SHEETS ATTACHED

MEASUREMENTS AND OTHER FINDINGS

20. HEIGHT

21. WEIGHT

22. COLOR HAIR

23. COLOR EYES

24. BUILD

25. TEMPERATURE

26. BLOOD PRESSURE (Arm at heart level) A.

SITTING

SYS.

DIAS.

SYS.

DIAS.

SYS.

B. RECUM- BENT

C. STANDING (5 MINS.)

27. PULSE (Arm at heart level)

A. SITTING

B. RECUMBENT

C. STANDING (3mins.)

D. AFTER EXERCISE

E. 2 MINS. AFTER

28. DISTANT VISION

RIGHT 20/

LEFT 20/

CORR. TO 20/

29.REFRACTION

30. NEAR VISION

CORR. TO

31. HETEROPHORIA (Specify distance)

ESO

EXO

R.H.

L.H.

PRISM DIV.

PRISM CONV.

32. ACCOMMODATION

RIGHT

LEFT

35. FIELD OF VISION

39. HEARING

33. COLOR VISION (Test used and result)

36. NIGHT VISION (Test used and result)

34. DEPTH PERCEPTION (Test used and score)

37. RED LENS TEST

UNCORRECTED

CORRECTED

38. INTRAOCULAR TENSION

RIGHT

LEFT

RIGHT W/V

LEFT W/V

/15SV

/15 /15

40. AUDIOMETER

RIGHT

LEFT

250 256 500 512 1000 1024 2000 2048 3000 2896 4000 4096 6000 6144 8000 8192

41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)

42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY

43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

45A. PHYSICAL PROFILE

P U L H E S A B C E

45B. PHYSICAL CATEGORY

46. EXAMINEE (Check)

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER

48. TYPED OR PRINTED NAME OF PHYSICIAN

49. TYPED OR PRINTED NAME OF PHYSICIAN

SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which)

51 TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY

A B

IS QUALIFIED FOR

IS NOT QUALIFIED FOR

STANDARD FORM 88 (REV. 10-94)

SLENDER

MEDIUM

HEAVY

OBESE

(Use additional sheets if necessary) 8.2.1.3144.1.471865.466429

NOTES: Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary:

1. LAST NAME - FIRST NAME - MIDDLE NAME:

2. IDENTIFICATION NUMBER:

4. HOME ADDRESS. (Number, street or RFD, city or town, state and ZIP Code):

5. EMERGENCY CONTACT. (Name and address of contact):

9. RELATIONSHIP OF CONTACT:

12b. ORGANIZATION UNIT:

13. TOTAL YEARS GOVERNMENT SERVICE. a. MILITARY:

13. TOTAL YEARS GOVERNMENT SERVICE. b. CIVILIAN:

12a. AGENCY:

14. NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS:

15. RATING OR SPECIALTY OF EXAMINER:

16. PURPOSE OF EXAMINATION:

REMARKS AND ADDITIONAL DENTAL DEFECTS AND DISEASES:

B. CHEST X-RAY OR PPD (Place, date, film number and result):

A. URINALYSIS: (1) SPECIFIC GRAVITY:

A. (2) URINE ALBUMIN:

A. (3) URINE SUGAR:

E. BLOOD TYPE AND HR

FACTOR:

D. EKG:

C. SYPHILIS SEROLOGY. Specify test used and results:

10. PLACE OF BIRTH:

6. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.:

8. SEX, FEMALE: 0

8. SEX, MALE: 0

11. RACE, WHITE: 0

11. RACE, BLACK: 0

11. RACE, AMERICAN INDIAN/ALASKA NATIVE: 0

11. RACE, HISPANIC WHITE: 0

11. RACE, HISPANIC BLACK: 0

11. RACE, ASIAN/PACIFIC ISLANDER: 0

3. GRADE AND COMPONENT OR POSITION:

DATE OF EXAM. Enter 2 digit month, 2 digit day and 4 digit year.:

A. (4) MICROSCOPIC:

F. OTHER TESTS:

A. HEAD, FACE, NECK AND SCALP. Normal:

B. EARS - GENERAL. INTERNAL CANALS. Auditory acuity under items 39 and 40. Normal :

C. DRUMS. Perforation. Normal:

D. NOSE. Normal:

E. SINUSES. Normal:

F. MOUTH AND THROAT. Normal:

I. PUPILS. Equality and reaction. Normal :

G. EYES - GENERAL Visual acuity and refraction under items 28, 29, and 36. Normal:

H. OPHTHALMOSCOPIC.. Normal:

J. OCULAR MOTILITY Associated parallel movements nystagmus. Normal:

K. LUNGS AND CHEST. Normal:

L. HEART. Thrust, size, rhythm, sounds. Normal:

M. VASCULAR SYSTEM. Varicosities, etc.. Normal:

N. ABDOMEN AND VISCERA. Include hemia. Normal:

A. HEAD, FACE, NECK AND SCALP. Abnormal:

B. EARS - GENERAL. INTERNAL CANALS Auditory acuity under items 39 and 40. Abnormal:

C. DRUMS. Perforation. Abnormal:

D. NOSE. Abnormal:

E. SINUSES. Abnormal:

F. MOUTH AND THROAT. Abnormal:

G. EYES - GENERAL. Visual acuity and refraction under items 28, 29, and 36. Abnormal:

H. OPHTHALMOSCOPIC.. Abnormal:

I. PUPILS (Equality and reaction). Abnormal:

J. OCULAR MOTILITY. Associated parallel movements nystagmus. Abnormal:

K. LUNGS AND CHEST. Abnormal:

L. HEART. Thrust, size, rhythm, sounds. Abnormal:

M. VASCULAR SYSTEM. Varicosities, etc.. Abnormal:

N. ABDOMEN AND VISCERA. Include he mi a.. Abnormal:

O. PROSTATE. Over 40 or clinically indicated. Normal:

P. TESTICULAR. Normal:

Q. ANUS AND RECTUM. Hemorrhoids, Fistulae. Hemolytic Results. Normal:

R. ENDOCRINE SYSTEM. Normal:

S. GU-U SYSTEM. Normal:

T. UPPER EXTREMITIES. Except feet Strength, range of motion. Normal:

U. FEET. Normal:

V. LOWER EXTREMITIES. Except feet Strength, range of motion. Normal:

W. SPINE, OTHER MUSCULOSKELETAL. Normal:

X. IDENTIFYING BODY MARKS, SCARS,TATTOOS. Normal:

Y. SKIN, LYMPHATICS. Normal:

Z. NEUROLOGIC. Equilibrium tests under item 41. Normal:

AA. PSYCHIATRIC. Specify any personality deviation. Normal:

BB. BREASTS. Normal:

CC. PELVIC. Females only. Normal:

O. PROSTATE. Over 40 or clinically indicated. Abnormal:

P. TESTICULAR. Abnormal:

Q. ANUS AND RECTUM. Hemorrhoids, Fistulae. Hemocult Results. Abnormal:

R. ENDOCRINE SYSTEM. Abnormal:

S. G-U SYSTEM. Abnormal:

T. UPPER EXTREMITIES. Except feet Strength, range of motion. Abnormal:

U. FEET. Abnormal:

V. LOWER EXTREMITIES Except feet Strength, range of motion. Abnormal:

W. SPINE, OTHER MUSCULOSKELETAL. Abnormal:

X. IDENTIFYING BODY MARKS, SCARS,TATTOOS. Abnormal:

Y. SKIN, LYMPHATICS. Abnormal:

Z. NEUROLOGIC. Equilibrium tests under item 41. Abnormal:

AA. PSYCHIATRIC Specify any personality deviation. Abnormal:

BB. BREASTS. Abnormal:

CC. PELVIC. Females only . Abnormal:

AGE:

46. EXAMINEE. Check. A IS QUALIFIED FOR: 0

46. EXAMINEE. Check B IS NOT QUALIFIED FOR: 0

40. AUDIOMETER, RIGHT,250 - 256: 0

40. AUDIOMETER, LEFT, 250 - 256: 0

40. AUDIOMETER, RIGHT, 500 - 512: 0

40. AUDIOMETER, LEFT, 500 - 512: 0

40. AUDIOMETER, RIGHT,1000 - 1024: 0

40. AUDIOMETER, LEFT, 1000 - 1024: 0

40. AUDIOMETER, RIGHT, 2000 - 2048: 0

40. AUDIOMETER, LEFT, 2000 - 2048: 0

40. AUDIOMETER, RIGHT,3000 - 2896: 0

40. AUDIOMETER, LEFT,3000 - 2896: 0

40. AUDIOMETER, RIGHT,4000 - 4096: 0

40. AUDIOMETER, LEFT,4000 - 4096: 0

40. AUDIOMETER, RIGHT,6000 - 6144: 0

40. AUDIOMETER, LEFT,6000 - 6144: 0

40. AUDIOMETER, RIGHT, 8000 - 8192: 0

40. AUDIOMETER, LEFT, 8000 - 8192: 0

33. COLOR VISION (Test used and result):

36. NIGHT VISION (Test used and result):

42.NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY:

43. SUMMARY OF DEFECTS AND DIAGNOSES. (List diagnoses with item numbers):

44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED. (Specify):

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER:

48. TYPED OR PRINTED NAME OF PHYSICIAN:

49. TYPED OR PRINTED NAME OF PHYSICIAN:

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN. (Indicate which):

51 TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY:

PHYSICIAN SIGNATURE. This is a protected field.:

DENTIST OR PHYSICIAN SIGNATURE. This is a protected field.:

REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE. This is a protected field.:

45B. PHYSICAL CATEGORY. A:

45B. PHYSICAL CATEGORY. B:

45B. PHYSICAL CATEGORY. C:

45B. PHYSICAL CATEGORY. E:

45A. PHYSICAL PROFILE. P:

45A. PHYSICAL PROFILE. U:

45A. PHYSICAL PROFILE. L:

45A. PHYSICAL PROFILE. H:

45A. PHYSICAL PROFILE. E:

45A. PHYSICAL PROFILE. S:

PHYSICIAN SIGNATURE. :

DENTIST OR PHYSICIAN SIGNATURE.:

REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE. :

37. RED LENS TEST:

NUMBER OF SHEETS ATTACHED:

IDENTIFICATION:

NAME:

20. HEIGHT:

21. WEIGHT:

22. COLOR HAIR:

23. COLOR EYES:

25. TEMPERATURE:

27. PULSE (Arm at heart level) E. 2 MINUTES.. AFTER:

27. PULSE (Arm at heart level) D. AFTER EXERCISE:

27. PULSE (Arm at heart level) B. RECUMBENT:

27. PULSE (Arm at heart level) A. SITTING:

26. BLOOD PRESSURE (Arm at heart level) C. STANDING (5 MINS.) SYSTOLIC:

26. BLOOD PRESSURE (Arm at heart level) C. STANDING (5 MINS.) DIASTOLIC:

26. BLOOD PRESSURE (Arm at heart level) B. RECUMBENT SYSTOLIC:

26. BLOOD PRESSURE (Arm at heart level) B. RECUMBENT DIASTOLIC:

26. BLOOD PRESSURE (Arm at heart level), A. SITTING SYSTOLIC:

26. BLOOD PRESSURE (Arm at heart level), A. SITTING DIASTOLIC:

28. DISTANT VISION. RIGHT 20/:

28. DISTANT VISION. CORR. TO 20/:

28. DISTANT VISION. LEFT 20/:

28. DISTANT VISION. CORR. TO 20/:

29. REFRACTION BY:

29. REFRACTION. S.:

29. REFRACTION CX:

30. NEAR VISION, CORR. TO:

30. NEAR VISION BY:

32. ACCOMMODATION. RIGHT:

32. ACCOMMODATION. LEFT:

35. FIELD OF VISION. RIGHT:

35. FIELD OF VISION. LEFT:

39. HEARING, RIGHT W/V, /15SV:

39. HEARING, RIGHT W/V, /15:

39. HEARING, LEFT W/V, /15SV:

39. HEARING,LEFT W/V , /15:

41. PSYCHOLOGICAL AND PSYCHOMOTOR. (Tests used and score.):

34. DEPTH PERCEPTION (Test used and score) CORRECTED:

34. DEPTH PERCEPTION (Test used and score) UNCORRECTED:

38. INTRAOCULAR TENSION. RIGHT.:

38. INTRAOCULAR TENSION. LEFT:

24. BUILD, SLENDER: 0

24. BUILD, MEDIUM: 0

24. BUILD, HEAVY: 0

24. BUILD, OBESE: 0

C. STANDING (3minuts.):

31. HETEROPHORIA Specify distance. ESO:

31. HETEROPHORIA Specify distance. EXO:

31. HETEROPHORIA Specify distance. R.H.:

31. HETEROPHORIA Specify distance. L.H.:

31. HETEROPHORIA Specify distance. PRISM DIV.:

31. HETEROPHORIA Specify distance. PRISM CONV. CT:

31. HETEROPHORIA Specify distance. PC:

31. HETEROPHORIA Specify distance. PD:

File details come from the government source that posted it. Updated May 29, 2025.