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METABOLIC DISORDERS INDICATE ANY ABNORMALITY OF THE FOLLOWING GLANDS BY A CHECK IN THE APPROPRIATE BOX AND EXPLAIN UNDER REMARKS. THYROID PANCREAS DA FORM 3437 NOV 2008 PITUITARY OVARIAN Previous editions are obsolete. DEPARTMENT OF THE ARMY NONAPPROPRIATED FUNDS CERTIFICATE OF MEDICAL EXAMINATION 1. NAME CAPS LAST - FIRST - MIDDLE For use of this form see AR 215-3 the proponent agency is DCS G1. Applicant must supply information below to heavy line Typewrite or Print in Ink 2. SEX MR* - MISS - MRS* 3. BIRTH DATE Mo. day year MALE FEMALE 4. STREET ADDRESS AND APARTMENT NO. 5. CITY STATE AND ZIP CODE 6. POSITION TITLE AND NUMBER 7. PAY PLAN AND OCCUPATION CODE 8. GRADE OR LEVEL 9. SALARY 10. NAME AND LOCATION OF EMPLOYING OFFICE 11. A ARE YOU NOW EMPLOYED IN POSITION SHOWN IN ITEM 7 YES B IF YES GIVE THE DATE OF YOUR ORIGINAL APPOINTMENT TO THIS POSITION NO 13. A HAVE YOU ANY PHYSICAL DEFECT OR DISABILITY WHATSOEVER IF YES GIVE DETAILS* B DOES THE VETERANS ADMINISTRATION RECOGNIZE SERVICE-CONNECTED DISABILITY IN YOUR CASE C HAVE YOU EVER RECEIVED DISABILITY RETIREMENT FROM THE U*S* CIVIL SERVICE COMMISSION OR SIGNATURE OF APPLICANT Sign your name in INK as it appears on your application in the presence of the physician for purpose of identification* DOCTOR All questions on both sides of this certificate and on the lower half of the attached Health Qualification Placement Record must be answered* Before beginning the examination refer to items 13 and 14 on the Health Qualification Placement Record so that you will have a knowledge of the physical requirements of the position to which the applicant is to be appointed* Sign both this certificate and the Health Qualification Placement Record 1. HEIGHT FEET INCHES WEIGHT 2. EYES POUNDS A DISTANT VISION Snellen WITHOUT GLASSES RIGHT LEFT WITH GLASSES IF WORN RIGHT B WHAT IS THE LONGEST AND SHORTEST DISTANCE AT WHICH THE FOLLOWING SPECIMEN OF JAEGER NO. 2 TYPE CAN BE READ BY THE APPLICANT TEST EACH EYE SEPARATELY. R* IN* IN* TO L* C EVIDENCE OF DISEASE OR INJURY RIGHT D COLOR VISION IS COLOR VISION NORMAL WHEN ISHIHARA OR OTHER COLOR PLATE TEST IS USED IF NOT CAN APPLICANT PASS LANTERN YARN OR OTHER COMPARABLE TEST 3. EARS CONSIDER DENOMINATORS INDICATED HERE AS NORMAL* RECORD AS NUMERATORS THE GREATEST DISTANCE HEARD ORDINARY CONVERSATION RIGHT EAR LEFT EAR 20 FT. 4. NOSE 5. PARA NASAL SINUSES 7. GASTRO-INTESTINAL A HISTORY OF PEPTIC ULCER 6. MOUTH AND THROAT IF YES IS ULCER ACTIVE QUIESCENT HEALED HOW LONG DATE OF LAST X-RAY SYMPTOMS PRESENT IF ANY Severity frequency etc* TREATMENT Use space under Remarks if needed 8. APD PE v1*00ES 9. HEART AND BLOOD VESSELS A BLOOD PRESSURE SYSTOLIC DIASTOLIC MM. HG* B IS ORGANIC HEART DISEASE PRESENT D PULSE RATE SITTING IMMEDIATELY AFTER EXERCISE UNLESS CONTRAINDICATED TWO MINUTES AFTER EXERCISE CARDIAC RESERVE GOOD FAIR OR POOR 10. LUNGS HISTORY OF TUBERCULOSIS NO. IF YES HOW LONG HAS THE DISEASE BEEN ARRESTED IF THERE IS HISTORY OF TUBERCULOSIS IS ANY TYPE OF COLLAPSE THERAPY BEING RECEIVED AT PRESENT FULL DETAILS UNDER REMARKS* IS MEDICAL SUPERVISION NECESSARY NO.

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