warren commission, volume xix: donabedian ex 1 - copy of
TRANSCRIPT
StAndw,dFnTtn 600Pmmulgnted Nov. 1952H)Bill
"II',- R.dget
Ci.W .l A--O]
HEALTH RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
. _ a+-Iffrs-t
SEP 111999
PIACEOF B]RTH"otlieinna
DONABEDIAN ExIIIBIT NO. 1
CHRONOLOGICAL RECORD OF MEDICAL CAREStand"na Fbrm "00
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (S//n .nchlnfr~)
U . S. MARINL CORPS AIR SIATT0I1-CAT T :049
at I
puCY.1W11',::e~.~sel"'
'rzzza-~T-s-B.
1l ClUNtilinil . yj h~ ";ioi1R _
7.n:TTZt̂ ~_ ~T ~EiLZi
~S~lV.1
:imnpf,' FROM ACTIVE DUTY IN THE USMC ON
& EFZL _-'J 11 Sep 1959_ -D-2E :
VA-al
T,
'~' R I N~ ~Y ',~ " 1 EI ; .I
HOC RACE GRADE. RATING.OR POSITION
Prc
ORGANIZATIONUNIT
sakes Se See
COMPONENTOR BRANCH
USMCSERVICE, DEPT . ORAGENCY
USNPATIENT'S LASTNAME-FIRST NAME-MIDDLENAME
i"t.7;A D e Ha aDATE OF BIRTH(-"AR)
18 Oct 1939IDENTIFICATION NO .
1653230
Standard Form RR(R ., ADC. 1ND)PRoNUKOATR. .T
HDERAD OF MR BUWRYQ-A-21
1
Oft
.n,owINELL ANDADDRESSIMb
U. S PAARINE CORPS AIR ST4TtON- L4ARFT{SANTA-ANA}t~AtfF,17. RATING OR SPECIALTY
AnNot
RIR1G
T
6. UNwLYS1l: A. 011 .
. 022AUPUMIM
I-
i INKERDfEGnDNEa NCO ND
..BLOW TYPE NO AI
REL 11 Sept ; 195.9REPORT OF MEDKAL EXAMINA1-rr1
tL mHG BIFORMATKXI
Rel : LuthernTIME IN THIS CAPACITY! TOTAL
d
CLINICAL EVALUATION
IL HUD. FACE NECK .AND
SCALP
If. NOSE
2n. SINUSES
21. MOUTH AND THROAT
2L EARS-GEMERId< draw. A- ..w.Y1"-- .ue w.. ;wm. .A,eK
IL mu .S (PerteM.)
24L E1111IERAL=Pw . ..a . "r . .A..:.e.rrw- r. a. .r 9n
25. OPHTHALMOSCOPIC
26. PUPILS (E.1vWYr 911/ reKlle.)
27. OCULAR MOTILITY ry"',°�'d'A,a ;�,1 t
w.R
2L LUNG, AND CHEST (Ied.dt Arcade)
25. HURT (71r.d, tln. rhIA1.,-.6)
30. VASCULAR SYSTEM (v koAw, ek .)
21 . ABDOMEN AND VISCERA (l.dfde AerNir)
7L ANUS AND RECTUM dN
A"p' A.e.IrKdrWv :rwl
3L ENDOCRINE SYSTEM
31. r-U SYSTEM
M UPPER EXTREMITIES d~
.-wN
36. PLAT
A. LOYirII EXTEEMmE5 NR.e.e h+1
7L SEINE OTHER MUSCULOSKELETAL
39. IDOITIFYRIG SOOT MARKS. SCAMS. TATTOOS
d SKIM. LYMPHATN3
11. NEUPOLOGk Itaaa-. r .. -A. Rae fn
41. PSYCHIATRIC
(cud AFM don)
a PELVIC
O VAGeUU.
O RECTAL
LAST SIX NORMO
-
riM-eq ~bnormdit) i detail. (Enter prtrrrnt Ire- nnenM'wmment :wntfnDS :nltsm7)enduPeadditionalihwEClfnwww~ .)
(39) S operation, 1" leS operation, 1" IILS
shot, left eS
left handVSULA
A
(18) Mastoid operation
dL MRITAL (P9.0 rowewkk ".6.1, wow wwM...On NIPyrr ad ls .ar Mdk ropedlnlf)
O~RfuwakMw
z-AFWNy ewu
(fxa).-PITHH W*,t, er«AorI-N-t-Ek"A YFYrRegAWhdrwMro led.de .Mtww.
J.
.
v
2
3
4
3
f
7
8 l-9
10 11 12 13 14
(continue IN
19 TS LE
II h iD a n a s a u n
.
a 21 2a 11 18 J?FT
6e1ar, wed
tWOUTM 1`101140189
dL CHEST X-RAY (P4or. dam, ABI aswb-, n.Y7
Ia. SEgLM MwoAPIrdownam
70mm #6318 - 3Sep1959LIGATIYE
4ML - MATDMOL OTHER "M
Lk)NABEDIAN EXHIBIT No . 1-Continued
ft mastoid
boar
1945 HCD
REMARKS AND ADDE70NAL DENTAL DEFECTS ANDDISEASES
TYPE 111
CLASS 1
QIIALIFIED
1 . LAST NAME-FIRST KAME-MIDOLE" NAME ' 2 . GRADE AND COMPONENT OR ICRI7gR L IDFNTIFICATION NO .
OSWALD Lee EArTG Pfo 1453230L NOME ADDRESS (N.wdar, deed w RFD, tiff F, hIIe, Cwle RIN Flak) L PURPoSE of EXAMINAT1011 f. DA" OF WAMIMTION
3124 West 5th St . Fort Worth Texas Se .rrt(:. - h"r - IIt 1 1M7. SEX ' L RACE ' f. TOTAL YRS GOVT. SERVICE 10. DEPARTMENT, AGENCY. OR SERVKZ 11 . ORGAMiIATIGM UNIT
M C or," , IIS11C H&HS SEP MCTs DATE a BIRTH IL PLACE OF SMITH IL NAME. RELATIONSHIP. AND ADDRESS OF NEXT a KIM
18 Oct , Louisiana Mrs M OSWALD Same as line 4 (M)
DtandaEd Form 02(Ilea . Aug. I'W)F-DMDLDA7BD Ar
BUN.A U
P-'CI--. A-2A
IS
MINING FACILITY OR EXAMINER. AND ADDRESSL . S . MARIL- COR , -~ SIR ST .1i .JN
- NJ-TORO (SAN TAANN.r""c17. RATING OR SPTCAI TI
ABnOR_
ec .femm-ppiopFSe7aco)MAL
enter "N E" iI not sr-lversdl. .
AsNot
REL 11 Sopt ; 1959
REPORT OF MEDICAL EXAMINAI .-N
I6 . OTHERINFORMATION
IuthornTIME IN THIS CAPACITY, TOTAL
DONABFDIAN EXHIBIT NO . I-Oontinued
3d
F---1-17
CLINICAL EVALUATION
19. HEAD. FACE NECK AND SCALP
19. NOSE
20. SINUSES
21 . MOUTH AND THROAT
72 EARS-GENERAL"."~°�� 17 o e,y>Ile
73. DRUMS (Perfmef(on)
L, EYES-GENEML~y� y�� ai,eo, e�je0~ZS . OPI - HALMOSCOPIC
26 . WNCS (Fqualdyandrmellon)
D. OCU AR MOTILITY7
21. LUNGS AND CHEST (Include bragi)
29 . HEART (71-l, ,(ee, rkgthm, aunde)
3D. VASCULAR SYSTEM (Varkorltlre, ek .)
31 . ABDOMEN AND VISCERA (Include Aernle)
3L ANUS AND RECTUM (N
f°'e'' A-rrO(P.wfef- J i"da1d1
33. ENDOCRINE SYSTEM
34. r U SYSTEM
35. UPPER EXTREMITIES (aM,we.,M
tiNe d
36. FEET
77. LOWER EXTREMITIES ~an.wW~~v,e/wafb"I
38. SPINE OTHER MUSCULOSKELETAL
39. IDENTIFYING BODY MARKS, SCARS, TATTOOS
d0. SKIN. LYMPHATICS
61. NEUROLOGIC (fae.T.A.iew
Ww741
62. PSYCHIATRIC (d-Va .,PweaWUad-arke)
(L1ak Oar Ioae)
LAST SIX MONTHSNO 65.-da«.be a erybno merry In defect. ( nrerpereinene :fen, n mar-
opmmenr~conrinvsmlrem73endMe-edd'rion- ah-eH
ft mastoidAbow
(39) S oporntion, 1" 1S oporntion, 1" US Llnehot, left eS r" left handVSULA
(18) Mastoid operation 1945 NCD
ALBUMIN
lUGAR
MICROSCO"C
70mn #6318 - 3Sep1959NEa
NEa
ND
NEGATIVE
VERL - NEGATIVEGI, WA
dL "DOD 7YFEAM FM
51.mm mmFAL7I0A
be,on -ech
1. UST -ME-FINST NAME-MIDDLE NAME 2 . GRADE AND COMPONENT OR POSITION 3. ID ON N10.
OS"OLD Loo IInrvo Pfo 30 -h. HOME ADDRESS (Numb", Aed a RFD, c0B or 1oun, em and 6fale) L PURPOSE OF EXAMINATION 6. Da ANIMATION
3124 Woot 5th St, Fort Worth TOXnS Soporation 3A " t 19597. SEX t RACE 9 . TOTAL YR9. rAVT. SERVICE 10. DEPARTMENT . AGENCY, OR SLRYICE 11. UNIT
C -0 L7TARY CMLIAN U X WLLL7
ORGANlIS~A~TION
LIP :ECIL DATE OF BIRTH 11. PUCE OF BIRTH 16. NAME, RELATIONSHIP, AND ADDRESS OF NEXT OF KIM
octi 3 1e Lo l"ie"n Mrs. 2.1, O~ lALD, some as lino '' ik (Li)
43. PELVIC O VAGINAL O RECTAL (Coatdaue In I -aI 7J)
k DENTAL (Plea approprlak
O~Raw.N'tedA
ambdo -Eau a Edoa
X.-Aflalng
number of upper ald Iowa teeth, reepedlae7)
kdh (! X d) .-tired bldg,, barhda fe
REMARKS AND ADDITIONAL DENTAL DEFECT] ANDDISEASES
I .-NaMrato.Ele fedh YX-X.-Replaed b7 denture Include abNgaumda
R ;f L TYPE 1112 3
G.
4 5
. .
6 7
.
6 I 9 10 11 12 13 14 15E CLASS 1
32 31 >j . 29 2d . . 27 X 5 24 23 22 21 20 19 16 FT E} QUALIFIED
LABORATORY FINDINGS
6. URINALYSIS: SP. GIL 1 022 k . CHEST X.MAY (Play &U.IUm number. ree,U) d7. SSMIOGY (SP-WPtad,ad,111/ga,2q
PRISM DtV.
PARNI CORY.
PC
PO
I Y. RED LENS
NCD
(BIN addBlew shad es of plahl Papa M "eras")
74. SUMMARY OF DEFECTS AND OIAGNDSES (Lid d6afran anVU Ilea ""Area)
7S. RECOMMENDATIONS-FURTHER SPECIALIST EXAMIMTIM INDICATED (Specify)
MEASINIEIIENTI AND OTHER FINDING1
n. TYPED OR PRINTED NAME OF DENTIST OR PCZ=lNdkde ark")
SIGNATURE
C .W. STEVENS,-CM. DC UMGE. TYPED ON PRINTED NAME OF REWwmG OFFICER OR Am1OVVa AUTHORITY
SIGNATURE
.. a. awvnme n wla maama
1~alne.-i
DONABEDIAN EXHIBIT No . 1-Oontinued
74.
PHYSICAL PROFILE
51 . HEIGHT 1t WEIGHT Sl COLOR HAIR S1 . COLOR EYES 1, BUILD: 1G. TEMP.
71 " 150 Drown Grey SLENDER ME''HEAVY OGESE Np p p
$7. BLOOD PRESSURE (Ann at heart Im ll $S. NL_E (Arm at heart lent)
SYS.IJ,V Sri' SYS.SITING AFTER EXERCISE I MIN. AFTER RECUMBENT AFTER STAMM"
SITTINGRECUM. STANDING SHIN.
DIAS.BENT DIAS. W mln.)
DIAS.
~~
19. DISTANT VISION 60. REFRACTION 61 . NEAR VISION
RIGHT 7a/ GI
"Of"'
TO A/ BY S CX I CORN. TO BY
LEFT 7a/ CO NK TO at BY S. CX CONN. TO BY
NONE P U L M E S
77.E%%INEE(CBnh) REIZASE FROM ACTIVE DUTY IN :THE USMCI5MOT QUALIFIED FOR
PHYSICAL CATEGORY
IL IF MDT QUALIFIED. LIST DISQUALIFYING DEFECTS BY ITEM NUMBER C E-
7y. TYPED OR PRINTED NAME OF PHYSICIAN
J.T. VINCENT LT. MC USNRSIGNATURE '
._w. TYPED OR PRINTED NAME OF PHYSICIAN " SIGNATURE
+~Nia
NEIEROPHORIA -.(SPRY, distance) ES* EX' R. N. L X.
63 . ACCOMMODATION BL COLOR VISION (no WW aRd ressu)
RIGHT LEFT 18/18 AOC 1940Fdi . FIELD OF VISION 167 . NIGHT VISION (7W1 Wed and aeare)
Ca¢nPany
A
_ August
AvnEle Rep1Bn
Me Oswald
T-First Naamo
Middle Name
Ser MOS
(Religion)
INFORMATION CONCERNII,'C NEXT OF KIN
liext of Kin (Full r,ame)_
HarBUrito Otwaldo o no f~~e~* case o emergency
Relationship Nothtir
ADD:3ES3
Permanent-_
w 6th Gt ,l. ?Qn~.aerth- T as
(r., St j;BMe
Temporary_
~Cero:czoaddress' Lt which next of kin willrebideafter yL,urdopae;ure for ovareops)
8':V : APRIL 1957
OVERSEAS DRAFT SECTIONAIRCRAFT, FLEET MARINE FORCE, PACIFIC .,
MEDICAL/DEV~UL EVALUATION
(If oily), .._ . . _
-
M~IUL XV;,"'I"
Needs Sh_AsNeeds X-gayIs Profile Disqualifying
Ia V^rine physically quaIs
Verino dontelly qual- - - - - - - - - - - - - - -
- . - - - - - - - - - - - _ -
Original (To Draft Company lstS9t)1 Gony to Meiica1 Drpfti Copy to Dental Draft
D1nORT1lNT : The original of this form will be turned into but T-666, Over- .seas Draft Section prior to departure of your. Draft for oversees.
DONABEDIAN ExHIBIT No . 1-Continued
YES Rol D 1I' .'~:".GN TING ES NO
( ) ( ) Needs Opnzative Dental ( ) ( )( ) ( ) Needs &urg3-y ( ) ( )
Needs Prosthetics ( ) ( )
lified for overseas duty (YES ) (NO )
fied for overseas duty . (YES_) (NO )
Rtnndmrd Form601Plomulgnted Nov . 1952BBy Bureau of tle Rud ..t
Clrcul.r A-31
HEALTH RECORDVACCINATION AGAINST SMALLPOX (Nvm6erolprevleuevkee)natbn .wr ) .
TRIPLE TYPHOIDVACCINE
TETANUSTOXOID
ANUUIf'H
SCHICK TESTING ANDDIPHTHERIA IMMUNIZATION
TYPHUS VACCINE
CHOLERA VACCINE
YELLOW FEVERVACCINE
IMMUNIZATION RECORD
DONAEEDIAN EXIiISIT No . 1-Continued
'ENTER RESULTS AS: IMMEDIATE REACTION (olimmunity); ACCELERATED REACTION (V.oe/void) ; TYPICAL PRIMARY VACCINA
Allentrlee In Ink to 6emede in block Ietten
IMMUNIZATION RECORDBtSOAYd YOM 001
DATE ORIGIN NUMBERRESULT "
-BATCHy,IDAY! FI. DAT.
STATION PHYSICIAN'S NAME
1
' DATE DOSE UNTOWARD REACTION PHYSICIAN'S NAME
..r e. i'~I1LS~~ ~~5!_ 11
DATE DOSE I UNTOWARDREACTION I PHYSICIAN'S NAME DATE DOSE UNTOWARD REACTION PHYSICIAN'S NAME
11 " I S
Is
DATE DOSE REACTION - PHYSICIAN'S NAME - DATE DOSE - REACTION - PHYSICIAN'S NAME
TEST ~$T
t f
.
. 7.
HYSICIAN'S NAME DATE DOSE REACTION PHYSICIAN'S NAME
!
DATE ORIGIN I BATCH NO .. l PHYSICIAN'S NAME DATE .- ORIGIN BATCH NO. PHYSICIAN'S NAME
7
. - ~110 ~ I I
I
DATE ORIGIN BATCH NO . - " - STATION PHYSICIAN'S NAME!
S
SSICK RACE GRAD[.RATING QI PCISITION ORGANIZATION UNIT COMPONENTORBRANCH BERVICE. DEPT. OR AGQ.CY
1~1PATMINT'S LASTNAMt-FIRST NAMK-MIDOLZ fAMB' I
i1'-;7,w pwlrTx: . . .l .DATE OFBIRTH (DAY-140NTIfYEM)
.-.SS~TrsrT.
ENTIFICATIONNO.
rsisry
R IMMUNIZATIONS
SENSITIVITY TESTS (=A,-U~ S.)
REACTIONS
1-" .90
BLOOD TYPING
==/
TYPE ".t"~°~~v
/
=FA==
I
PHYSICIAN'S NAME
REMARKSAND
~^i- ^~
~,^°.
-'--~'~-- w«pmy»woomGO ^«n^""~`'/c~~.~~~v~~~Balk.
~»p,y ~,°=°= wr---- -----
d
-------'~---
oom:'-- - '-"_----m~**~*om:-- -
/----'m=*** ~~. .^^^°m°=~ -_.--
^~--_._
_----
~~
_- __--_--"=T77;77 ,- /W-'~'
'^~p'J
!
/;r~.^
~~
.'--'-'
'--
1.` .01~40'
~~
~~~~
.~~~~^~~~~~--~-1 "-477=`
nONABEDI^ EXamIT No. 1-Continued
' ?
--4WSICIAWS NAME
1314
DWATR AGD(T TYPE OF RLACTION SEVERITY PHYSICIANS NAME
StandardVbTmONreomulpttod Nov. 1063By Bmooa of the Budgt
CYwaor A--J3
HEALTH RECORD
CHRONOLOGICAL RECORD OF .MEDICAL CARE
SO-W7Wl
DONABEDIAN E%HIBIT NO . 1-Continued
CHRONOLOGICAL RECORD OF MEDICAL CAREBtand.M Bbrm SW
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION ($4nooohontp)
LaOct56 USMC-RS DALU S, TEXAS
8 S OCT 195 AicitU, SAN niE0O, CAL JAN )e
' ' ist CAMP SAfV OfdCFFC DISf HISARY ,
' MAR1957 FIATTC, RAS, JAX, FL7�
i) UUL 1ybl ~Ar 1557
EPt 1 8.1957 s>< .r1~Jc~tuwa a..a .-ma w. &RB OCT, 23,1957
10-27-57 USNH NAVY ~n, I n r3923- - Ac - i 1& 7- !//A !r!
lMEDICAL DFPkl ialM" t_f k1TT1D ' ~~ "i~ib t tU. S. MARINE CORPS AIR STATION
X '(fig-p;~KFq AyM)~ r"AI Ic
'+ RATION IF ENLISY'kEN'1 SEP 115959
r
-.t9ilC'
.,utr
_
1Iy ~~{9
sex RAGE MRRDE, RISING, OIIrOSITION ORGANIZ^T10N UNIT COMPONENTOR MRANCH SERVICE, DEPT . OR AGENCY,M USMC . '
PATtM'fLASTNAM~IRSTNAME-MIDOLBNAME DATE OF MIRTH (MFY7Rw'Yt/~11) I--III-TI-NO.OSWALD, Lee Harvey 18 October 1939 1653230
i a..mot w~mww~ ~.- .111
DONAHEDIAN E%IMIT No. 1-Continued
DATA NYMPTOMS . DIAGNOsIs. TREATMENT, TREATING ORGANIZATION (Slim each enty)
FT 10-,47-5 U/M, UPPER LT . ARM #8255 D NOV , ~J1 195r
r 10-6- 8 URETTIS ACUTE Rdn-Venereal (6072) DNEPTE10-10-54 :1 SIGMOIDOSCOPY (444) LmWPI-13-54-; (7)
r.r.9J1
r~y0
kv
c . Y
6~9~ '
fc4~
fL,
.`i
efndard Pbrm RR(Rev. Aug. IM)
PROMULUATRD .Y^ II-E . . Or TUa LUDU.TC- A-2A
IS. EXAMINING FACILITY OR EXAMINER AND ADDRESS
IL OTHER INFORMAT"
AnS, Dallas, Texas
Relig2 Protestant17. RATING OR SPECIALTY
he h~rORT OF MEDICAL EXAMINATION -
TIME Rt THIS CAPACITY: TOTAL
CLINICAL EVALUATION
33. ENDOCRINE SYSTEM
I34 .G-U SYSTEM
35. UPPER EXTREMITIES
II'I' Nna
36. FEET
37. LOWER EXTREMITIES i9ngA~
pe/,Mien)
36. SPINE OTHER MUSCULOSKELETAL
39 . IDENTIFYING BODY MARKS. SCARS, TATTOOS
40 . SKIM. LYMPHATICS
41 . NEUROLOGIC ,ce.4aeI ... hr.-tun 78)
Q. PSYCHIATRIC (Bath an .P-t4.deaaken)
(Cheek hmo done)
43. PELVIC
O VAGINAL
O RECTAL
4'18 . Mastoid operation 194
EAST SIX M"N"O
-
rib. .vu) boor
bit) in da. . (
t.rprlin.nt item number before . .ohaommsnl : eontinw In Item73 .nd u . . Addition,, .A ..te IAn.a.t. .rs
(conelnw In l
F.m .l
4E DE7RAL (Plant epprnpuua-Ymbdt abate a bdom number of upper and Utter teeth, retpedlcelr)
LABORATORY FINDINES
Q. URINALYSIS: SP. Oft
1 .018
46. CHEST X-RAY (Ptaa, 4814 Jun number, Feltln
n. SEROLOGY (9pa1/FAnd wiow reran)
ALBUMM
SLOE
MICROSODM
1
. .
_
N
N
ND
''RD-17
:Z bL.
-,
, . . . . -.
:. :._
L WA
A. BLOODTMAPO Rll
IL OTHER To"FACTOR
NND DC
DONABEDIAN EXHIBIT No . 1-Continued
5 VCD
.m 73)
Acc
REMARKS AND ADDIIIORAI DEMAL DEFECI9 ANDDISFASE4
Is-eaeF9
L LAST NAME-FIRST NAME-MIDDLE NAME L GRADE AND COMPONENT OR RIBIT1011 L IDENTIFICATION NO.
C6wpTD, Lee Harvey APP USMC4. HOME ADDRESS (Number, Oral a RFD, CUP a tatter, aaM end $kk) L PURPOSE OF EXAMINATIGR L DA OF
4936 collinwood St, Pt worth, Tex enlistment USMC 24 Oct 567. SEX( 6. RACE 9. TOTAL YRS WVT. SERVICE IL DEPARTMENT, AGENCY. OR SERVICE 11 . ORGANIZATION NOT
]I. Is cauo MILITARY CMLWI 7tA\3!"
I2. DATE OF BIRTH 11. RACE OF BIRTH IC NAME
.
RELATIONSHIP. AND ADDRESS OF NEXT OF N1R
18 Oct 39 D1ew Orleans, Ia Marzierite Oswald Mother Sam e as
o .-Rettaablel.-Novr.torabk
teethtrd, XX
R.-A7ktIRg.-lkplaee4
tu4b9 dentueat
(d X d) .-FTred bridge,Indudc abodmr.W
brackel1
1 2 3 4 9 6 7 6 9 10 11 12 13 14 13 1B LE
F32 31 30 29 26 27 26 25 24 23 22 21 20 19 16 17 T
NORMAL BNORMAL enter
".m .n .paroPn .e . co -"W ei1 nOt . ..m.t .en
_x I0. HEAD. FACE NECK AND SCALP
x 19. NOSE
_X 120. SINUSES
_X 21. MOUTH AND THROAT
x ZL EARS-GENERAL e vMn ,Nm, >0 aM7a)
_x 2L DRUMS (7Vrfaatlan)
_x 24. EYE' GENERAL AVM=Sy. a.dlt)~
_x 23 . OPHTHALMOSCOPIC
x 26. MIMLS (Equality and reaction)
x 27 OCULAR MOTILITY (Am�-aPa- 393 No marks, ANT .x 28, LUNGS AND CHEST (Include breath)
x 29. HEART (Mud, OFF, TA,Mm, munch) POSTS pea rt e scapular; sj" It hand ; vsala;x 30. VASCULAR SYSTEM (LrariceOtlea, INC .) ops 3" It mastoidX 31 . ABDOMEN AND VISCERA (Indudt htrnk)
X 3? ANUS AND RECTUM (NSnenAed,. Aw.lae)(P4s.W J iMvat.n
- - StA d.
-99(M .UX.10.10) -
PAOMVLOA1RO B7
. "
REPORT OF MEDICAL HISTORYBURRAU OF TH . BUDDBTCIRCULAR A-BI
THIS INFORMATION IS FOR OFFICIAL RE ONLY An WILL NOT BE RELEASED TO LRANTNORIZEO PERSONS
I . LAST KAME-FIRST NAME-MIDDLE NAME
E. GRADE AND COMPONENT OR POSITION
0MALD, LEE 1'ARVEY
APpT.Trn7JT1. NOME ADDRESS (NBAber, Wed or RFD, city or two, tow and State)
S. PURPOSE OF EXAMINATION
IS. EXAMINING FACIl1TV OR EXAMINER, AND ADDRESS
19. OTHER INFORMAigN
AFr',St_III4AS, TEXAS_
I
RIMS Luthuran
17. STATEMENT OF EXAMINEE'S PRESENT HEALTH IN OWN WORDS ("m SF /taelytlee oftnal AW", yeemphin1 "big)
Tel-L.. _. r
744-730 0-64-vol . XIX--39
20. HAV E YOU EV ER HAD OR HAVE YOU NOW (PMrt duck at Jeff of each Neat)
DoNABEDIAN ExHIBIT No . 1-Oontinued
L DATE OF EXAMINATMII
OCT 24 1956) , Q16 r-11inAQQd to, rt, . ti7o t
Texa
enlistment7. SEX
-
L. RACE
S . 70TAL 7RS. GOVT. SERVK2
10 . DEPARTMENT. AGENCY,OR SERVICE
II. ORGANIEATm LRIITMILITARY LIVRIAX
ValeUSM 112. DATE OF sin"
17. RACE OF BIRTH
14, NAML RELATIONSHIP. AND ADDRESS OF NEXT OF KIN
4936 Gollinvwd St.,
1(1 Oct ao'
a
Marguerite ('7 :IkT.D ( ;'(7TTR) Fort Worth, Texas
U. HAS ANY BLOOD RELATION (Parrot, brother, abler, other)
091
. "RELA TIOR AGE STATE OF HEALTH R DEAD, CAUSE OF DEATN ATX YE! NO (Check sRCIII item) RELATION(S)
FATHtRI-~~ IP ~~(~IIIAIA~.a-~`
NADTUBERLUIOSIS _
MOTHER -~ HAD SYPHILIS
SPOUSE --~J HAD DIABETES
--~ HADCANCER
BROTHERS HAD KIDNEY TROUBLE !
AND F.A . HEARTTROUBLE
1
11GFm HAD STOMACH TROUBLE
-~ HAD RHCUMATBM (ArtArftlt) !-
CHILDREN 1"" HIVES-HAD EPILEPSY (FW)
~'. COMMITTED SUICIDE
BEEN INSANE
- -
©
© --©©(Chock each itom) M"01 each item)
J1 SCARLET FIVER. ERYSIPELAS 1 .41GOITER TUMOR. GROWTH. CYST. CANCER OR LOCKED KNEEIP i'TRICK" '
i A TUBERCULOSIS RUPTURE " `" DOT TROUBLE
(Night -.14)-
APPENDICITIS k ~1EURRiS'PAMLY515SWOLLE .OR PAJ.1U I(fw. MJaafY<)
.r/ L EPILEPSY OR FITS
ICAR. TRAIN . SEA . OR AIR SICKNESS
SUGAR OR ALBUMIN IN URINE "®FREOUEMT TROUba SLEEPING
FIEGUOrr OR TLNR_INO N.-RE3
DEPRESSION OR EXCESSIVE WORRY
1r LOSS OF MEMORY OR AMNESIA
WETTING
CHRONIC OR F1 NERVOUS TROUBLE OF ANY SORT
SEVERE TOOTH OR GUM TROUBLE
,"~A r
.vrANY DRUG OR NARCOTIC HABIT
-~..
. . "~ EXCESSIVE DRINKING HABIT
"~ . "R HOMOSEXUALTENDENCIES
E1 . HAVE YOU EVER (Check each itom) u FEMALES ONLY : A . HAVE YOU EVER- 0. COMPLETE THE FOLLOWING:
"
8EEN PREGNANT AGE AT ONSET OF MENSTRUATION
_ ..F . ..I HAD A VAGIRALDISCHARGE INTERVAL BETWEEK PERIODS
r " - .. ~ .. EEDI TREATED FOR A FEMALE MSO WRATp11 OF PERIODSn 41 Or.. ~~ .. L MENSTRUATION ~- DATE OF IAST PERIOD
.. GI NAD IRREGULAR MFNSTRUATKNI OUANTRY: /~/O/,wr/O/,wrm
EL. NOW MANY IOBS NAVE FMPAST THREE TFAILA
24 WHAT B THE NN) YOUMOMIbNF1DARY OF TIIElL
O. WHATS YORK USUAL OCCUMTNMw E4 ARE YOU (Chock Rno)
YBIrIBI~ _IIYO
I
O. IUAYE YOU KEN
US",
TO KaD A Ja"",
( l
SENSITIVITYTOCKEMIUU .am.SUNUDNT.M
MD
S. MASIUTY TO FER"AI CERTAIN MOTIONS
CHECK EACH ITEM YES ON NO. EVE
C. INAMLM TO ASSUME CERTAIN POSITIONS
D. OTHER MEDICAL REASONS(Iyoo, give reatom)
n. HAVE YOU EYED WORKED WITH RADIOACTIVE SU&STAMM
D . DID YOU HAVE OIFMULTY WITH SCHOOL STUDIESON TEACHERSt (it y- . dlve detail .)
A HAVE YOU EVENKI7IREFUSEDEMPLOYMENTKCAUSEOF YOUR HEALTHI (If)n, tote naton and girtdetails)
SI. HAVE YOU EVCA BEEN DENIED LIFE INSURANR1(try. ., tbu noon And
girt of.'aft.)
SL HAVE YDUHAD. ORHAVE YOUKENADVISED TO~VE,ANY OKRATMS7 (lf jr-, de.orib, and divaq. at which -. .,,ad)
D. HAVE YOU EVER SEEN A PATIENT (eommittad orrohrnfarl) IN A MENTAL NOSPITAL0. SA .TOR-IuM1 ((Ilst, tpcdl whm, who., ,rhl, and
or d
tor,
Ad oompltte .ddrew ofhwpifelw ehnle)
RE. HAVE YOU EVER HAD ANY ILLNESS 011INJURY OTHERTHAN THOSE ALREADY INEND' r(lf yet. tpeeif)when, who,, andgin dot aila)
SE. "VE YOU CONSULTEDOR SEEN TREATED SY CLINICS.PHYSICIANS. HEALERS, OR OTHER MACTItIO ERSWITHIN THE PAST S YEARS? (If let. dive com-plotd detail.) of doctor, hop,ital, clinic,
X HAVE YOU TREATED YWRSELF "ILLNESSES OTHERTKN1N M1NDI1 COlD51 (Illo. which .note .)
A. HAVE YOU EVER KEN REJECTED MR MILITARYSERVICE BECAUSE OF PHYSICAL MENTAL OR OTHERREASONS? (If let, dirt date and roton forrvectron)
X NAVE YOU EVER KEN DISCHARGED FROM MILITARYSERVICE KCAUSE OF PHYSICAL MENTAL OR OTHERREASONSI
(IIlet, dive dde, r d
=rehanlhonoiabN .
for
tunAtn~moor ue-.uit.bilitl)
SI. "VE YOU EVER RECEIVED. IS THERE PENDING, HAVEYOU APPIJED FOR, OR DO YOU INTEND TO APPLY FORPERSON OR ODMKNSATIOX FOR EXISTING DISIML.
wh-!and hot -..t. -he.. arhy)
Yo
TYPED OR PRINTED RIME OF PHYSICIAN OR EXASA
to nA`MDs#' L!
MY frtU CIECKED°YO . . MUST K FULLY EXPLAMO IN SLARK SPACE O1 RIGHT
1 CENT)" THAT 1 HAVE REVIEWED THE-FOREGO100 INFORMATION SUPPLIED MY ME AND THAT IT h TRUE AND COMPLETE TO THE REST OF MY KNOWLEDGE.1 AUTHORIZE ANY OF THE DOCTORS. HOSPITALS, 011 CLINKS MENTIONED MOVE TO FURNISH THE GDVEMMENT A COMPLETE TRANSCRIPT OF MY MEDICAL KLOMO PON MIRPOrorPROCESSING MY APPLICATOR FOR THIS EMPLOYMENT ON SERVICE
TYRO O1 MINTED NAME OF EJGMIXEE
9IMA71RE
~ "Dl ~JYP
I,~-L MYSICAM 5 SUMMARY AND ELAIDIIATION a ALL /ERTINOT DATA (PRphb . NDNAMfMMM
yrgNt BRNMNFN AI EfWMb
_ . n,
s
DONABiEDIAN EBHIBIT No . 1-Oontinued
" .
ANNUAL VERIFICATION
SQUADRON NAME
/V
RATE OR RANK--,,~-G SER. NO . / z' S',3-,'?, :3~~
NEXT OF KIN & RELATIONSHIP
A?
tvl1laPERMANENT ADDRESS
31
y
W' '"Sf'~ . Sl~
&k
LdOR T)l - T. X12whre to notify next of kin in case of accident
DATE OF BIRTI{,Og,T
STATE OF BIRTH
LA .a
RELIGION
Pxn7
BLOOD TYPE
DoNABEDIAN EXHIBIT No . 1-Oontinued
etAndnM FYxm 11n6P-WR ::M Nov. IUSEB, Dumnuof the fdpt
Clrcul.r A-37
RACX GRADE. RATING . OR POSITION
ri1/_ .WIN.jME" .i1'.
�
r .,
(~a~rrrra~~yop.
ORGANIZATIONUNIT
491-' ILTVD
COMPONENT OR BRANCH
OATSOF GIRTH (Mr-Helm-r
)
DATE
SYMPTOMS . DIAGNOSIS. TREATMENT. TREATING ORGANIZATION (Si/nsACA .nerF)
O
t , :, . . 1 1 ,
SERVICE. DEPT. OR AGENCY
un
IDENTIFICATION NO .
HEALTH RECORD
I
CHRONOLOGICAL RECORD OF MEDICAL CARE
81 i)Cl 1960 DQUARTERS, MARINE AIR RESERVE TRAINING COMMAND
opped this date by reason of discharge from the U. S. Marine
DONABEDIAN EXHIBIT No . 1-Continued
--- CHRONOLOGICAL RECORD OF NEDICAI,CAREbNBGWJbn0tB.
74. SUMMARY OF DOECTs MID DIAGIa80 (LAW disPoameIt with ANN% n .mbes)
NCD
MEASUREMENTS AND OTHER FINDINGS
I certify that I have been informed of and understand theprovisions of BUbED INSTRUCTION 612oa6
Signature
b . TYPED OR PRINTED NAME OF PHYSICIAN -
I
. ,
I SIGNATURE
n.TYPEDORPRINILDNAMEOFDOR6TOR
(Indicate which)
-
-
SIGNATURE
C.W. STEVENS, CDR. DC, UMa TYPED OR PRETTFD NAMEa REYIEWM OFFN7R OR APPROVING AUTHORITY
SIGNATUREF ~ .
(UFF ddBbwFMAB a/ pial- papaY~1)
R.,IaFMa!RgTI T+IRIRawPIRI Z ts-Bep " S
DONABEDIAN EXHIBIT No . 1-Oontinued
NUMBER OF AT.TACHED SIN=
SI . HEIGHT SL WEIGHT S7. COLOR "AIR SI . COLOR EYES SS. BUILD : SS. TEMP.
71 h 150 Brown Grey SLENDER ME'MHEAVY OBESE Np o o
$7. BLOOD PRESSURE (Arm at Mad met) 50. PULSE (drm W heart lead)
SYS110 SYS. SITTING AFTER EXERCISE 1~J ARER STANDINGSIRING RECUM.
!YS
.STANDING
I MIN.UIAS. BENT DIAS . (0rdn.l
DIAS . -V459 . DISTANTR'ISIOM 60. REFRACTION -61 . NEAR VISION
RIGHT 10l 2 CORR. TO 20 BY A CX CORR. TO BYLEFT N/ CORR. T O 20l BY S. CX CORR. TO BY
73, RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED (Sp"dlr) 76. PHYSICAL PROFILE
NONE P U L N E S
n . rINEE (a"A) PE~~ FROM ACTIVE DUTY IN VHS USKC0 IS HOT OUALIFIED FOR PHYSICAL CATEGORY
71 . W NOT QUALIFIED, LIST DISQUAUFYIBG DEFECTS BY ITEM NUMBER . . -. ; C E
i7s. TYPED OR PRINTED NAME OF PHYSICIAN
J.T . VINCENT . IT, MC, USNR
RAs WAVY 3835
(,
'
SICK CAII TREATMENT RECORD
-c,.wxa n~w"n
DONABEDIAN E%HIBIT No . I-Oontinued
~-̀Fuon
No.
,~ ~~`3Z3
DATE COMKAIM PAS NAVY :583TREATMENT DISIOSITION ,NIT,
69 Jp
,
_
IIL , ._W--SIrC ~~NO .~ ..~ tt.~ .
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" -s1CK CALL TREATMENT RECORD
10-!
DONABEDIAN EBHniIT No. 1-Oontinued
1n! o! 0eevla No .
/(o J
.) 3 T o
Ah /-9C S- /
HAYYED.H .10
111 .151)
RAW
SICK CALL TREATMENT RECORD
DoNABEDIAN EXHIBIT No . 1-Continued
MACS-/
FILE 1511 SERVICE NO ./1,5--3 .R 3 D
N AYIACD" N . 10It1 .51
SICK CALL TREATMENT RECORD
°. " r D'.ec.o, Cu13Y .
NAMEOSWALD,LEE H. PVT. PLT.2060
1663230FILE ON seence No .
DoNABEDIAN ExHIBIT No . 1-Oontinued
SICK CALL MUD= RE1Ytru)
Name dSwALb Lee; N.
Service no. 16y32Wtar F.
i.r . t
middle,
IA
s - I
DONABEDIAN EXHrsIT No . 1-Oontinued
MAG-11 . DISPE1SARY . . . . . . . . . . .
SICK CALL TREATTMI'P RV,4i,
Yq" o r f
Name
e~ .2fl-46 A-4,last, ftr:t middle
DONABEDIAN ExHlBIT No. 1-Clontinued
-av .--__-_----------------
"
SFNSITIYITY 'irIST
-pihydroetregtoWcin
100 mcgmStreptoacin
100 mcgmPenicillin
20 Units6ureorgcin
30 mcgLl -^TorraNcin
30 ricgm_ --Tetracycline
30 mcgm -V-Erythrwmycin
30 LimnOnloromyaetin
30 mom -i- -f'Sulftii azino .
30 mcgm --f1fasomazole
30 mcgm --Nitrofuradantoin_- _
30 mcgm,-_-
DONABEDIAN EXHIBIT NO. 1-Continued
[.:
VEOpoIMo sou~et
uuwna'wh Moues'.
Fr
,
F
w-~F~ aw r~.e r.w
urr
sr~..rw~~w-cti+drUCTEMOl00Y
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II
SICK CAII TREATMENT RECORD
T
got
Sl, lL D .Lce
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ffLJ'OR SERVICE 30 ..,...
DONABEDIAN ExHIBIT No . 1-Oontinued
MACS-1
toj~53230
DATE COMPLAINT TREATMENT DISPOSITION IN IT .
FAVT aeae .
' 16.W UR$'1'HRAL DISCHARGE TO LAB XCffi SMEAIO AM NEGATIVE DIPLOCOCC :
D FXTRMYT.T.nTdR Mna ~_
~ sEmBLIna HEIBSI~IA oo~ococcr -
".!'I. Cpl i
1 r
rat"
1
r P
BAB NAVY 3835
T
URETEiRAL DISCHARGE ;~W;aty~Inu+~~[y ~~
P.23.1958 sl "~ .~ " SMEAR: bSANY PII3 CSIL3, NO RGANI:
' 'UIUS : IdICROCOC)C PYOGEN VASAUerrvd
Coo--w tc Y c9 .
SEP
17
DONABEDIAN EXHIBIT NO. 1-Continued
. " u. s Aarnmrm nmnm onv:Is" o-sr
DATE COMPLAINT TREATMENT DISPOSITION INIT .
AS WAVr 3838
. 2 9. f9-58 URETHRAL DISCHARGE :SMEAR
MANY PUS QUIZ120 ORGANI" NOTED
I
z- _ .. _L - 1__--
US WAVY 303
URETHRAL DISCHAEGE W~ -
MODERATE AMOUNT 0POSITIVE COCCI
04C.41 C-4
I-
i
t~"..gym
V
~~N
.
.-
Y
btandlvd PbM lmdPromulgated No. . 1953SBy Bureeu of the Tudpt
Clmular A-7g
HEALTH RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
DONABEDIAN ExHIBIT No . 1-CJontinued
C"ROMKOQICAL RECORD a MEDICAL 909ennd.rdFarm 4 .. _ .
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sid. ..oA .nep)
;7"STiT~ -YI Lao. N%02~-
9/16/58Origin : In line of duty, Not due to own misconduct .
"l_"TRSf-~.T-e71L5GTi~C~S1" a A1,-ht rli-~Ci3r,~e and ii~'~7S-1rJ~iy;sensation on urination.
P$ : Previous. V .I). :
PE : Essentially ne,;,itiae except for a thick mucopurulent
-diplococci havirC the morphology of ff . Gonorrhea.
RXI Procain Penic1llinqMiCM- Units I.14. X_4_-days
9/16/58 4o duty under treatment and observation : ,
PES-1421(VD) submitted : 11o-B_754r- r
tea:.muaarm+r"n
CAPT.M:A11JI :Jyiy~i . .
USN
t
APPROVED ;
11 LIP- ICAPI i1C U iv
~Xx
Rl1CZ
cGRAM RATING,ORPOSITION
PVTORGANIZATION UNITMACS 1 MAO
COMPONENT OR RANCH
1 USMCSERVICE, O[/r . OR AGQICY
PATI[NT'SLASTNAM[-FIRfTNAM6-MIOOLZ NAMEOSWALD,Lee Harvey
DATE OFBIRTH10/18/39
(mom) IORlTIPICATION NO.1653230
D
A
e°:a
Bad932
O .tCl,cvlar A--32 J-82094 Wd -A
USMCM I C I PFCPATIENT'S EAST NAME-FIRST NAN---*IDDLE NAME
OSWALD, Lee H.DATE OF BIRTH (DAY "MONTII-TEAR)
IDENTIFICATION NO.
18 October 1939 (_1653230
DONABEDIAN EXHIBIT NO . 1-OOIItinued
SEX I RACE I GRADE, RATING, OR POSITION ORGANIZATION UNIT I COMPONENT OR BRANCH I SERVICE . DEPT. OR AGENCY
(R:OIIOL06KAL EECDIID OF RLDI:AL GEE/Irni
HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE SYMPTOMS. DIAGNOSIS. TREATMENT . TREATING ORGANIZATION (Sign wch MS")
U.S . NAVAL HOSPITAL NAVY No 9 2
27 0 DIAGNOSIS : WOUND-MISSILE UPPER LEFT ARM GUNSHOT NO A OR N
INVOLVEMENTh t co
L*255and - work
2. Patient dropped 45 caliber automatic, pistol discharged wht truck the floor , and mi sae struck :atient in left arm
causing the injury .NARRATIVE__SUMMARY :
This 14, year male accidentally shot himself in the leftarm with a idearm_ reRortedl of 22 caliber Examinationrevealed the wound of entrance in the medial portion of theleft uTT!er arm Just above the elbow There was no evidenceof neurologic circulatory, or bony injury . The wound ofentrance was allowed to heal and the missile was then exciseethrough a separate incision two inches above the wound ofentr The missile a ""Ieared to be a 22 slug. The woundhealed ;We-1 and the patient was discharged to duty .SURG : 10- - : FOREIGN BODY . REMOVAL OF FROM E7tTEMITIES
5,195A~ 1~7Z»I,~.\au
Discharged o duty, fit for same,
Y.--s-
LT MC USNR.IG$THRIE -
AP'ROVED :
H. M. WERTHEIMERCAPT MC USNCHIEF OF SURGERY
Standard FnfmWO
~IPnmulllnud Nov. 1059BT 1111-of t5M Fl-A[.-
Clrculu A19
744-730-0-64-vol . XIX--40
DONABEDIAN EXHIBIT No. 1-Oontinued
HEALTH RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
CHRONOLOGICAL RECORD OF'MEDICAL Wt- SanGBearDnL.lwB, .
607
0 DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign NOh entry) --
)
Y v a ... US:Ioa\J' ~; .Lt iV_ y " .'Litt T\ Al) U--In.-., .771W
tn;;a iinq'_1
transferhis ,late an ova-LC. o Le
beyon: the Continental liphysicallyx.ts of the
qua lfle(- . DrUnite,-:. Statos,~
., . ,,r .- .y,,--
IS
(
date :
195 r~ .9a- t . t'LL v.! .'''1 aJ i
i
SEX RACE ATING, OR POSITION . ORGANIZATION LIMIT
'm Av . 072.,PATIENT'S ME-PIRSTNAMErMIDOLtNAMB
r~ c Lvt4 JA
.~e er 11AIQ '
COMPONENT OR BRANCH SERVICE, DEPT . OR AGENCY .
DATE OFBIRTH (tnr-NafnMUn) IDENrIFICATION"0.
0 t ,-e x '% l~,5-,3aa3o . ,
Standard Form ONPmm,IS.kd N .r. 1967By Balms Ithe Hue~.t
ch.ul.r A-m
HEALTH RECORD
I
CHRONOLOGICAL RECORD OF MEDICAL CARE
iA .o+ L' . 4
47_L
Sf1 . Vi
't,`URONOioalau RECORO Or MEDICAL- CARE
etandwe yorjik on . -
DONABEDIAN E%HIBIT NO . 1-Continued
- SAT[ SYMPTOMS. DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (SJgR~h .mel)
U. S MARINR CORPS RECRUITD;P(Yr, SANDIWO.T
ACAIWOtN(Ai
. . . . .__ ._ .H1oadKkre Negsllve
. . . . . }Ifmat lhrAU!Iaurryr.Pl,ie Ch," Fib- }In, KPl O
:frrr«rrrrn~rr~rtj
? . :r- U . b . GU-<r.i lr 1.!~'YUP r :;I.K LJP:GU 4'J, UAL.ikOHNiAa . . _ " 11 :1[- L1l :JC MMV Jy9C, ., . . .. . . .u - :;Vl - OaIIC 10-OV r
Ilnd {mind to ho bhv31Cally mialifjod (Of tranpfAT . r
D. ,
WATECHTRACCN JACK50NVILLB. PL11.
to be physically quatifid Ia
l
laeuedthis date :,
SLXY
RACE
OauGRADE.RATING,ORPOSITION
Pvt,ORGANIZATION UNIT
uSwCOMPONENT OR BRANCH SERVICE, DEPT . ORAGENCY
PATIENT'SLAST NAME-FIRST NAMI9--MIDOLENAME
OS"IALD . _Lea- Harvey r._
DATE OP BIRTH (Gr-Ywrneg~)
18 Oct . 39 .IOEIITIPICATION NO .
.-i~̀ ~ .2 J
ef .ul 0. fil[ N..[ .
ic .
_-
-
I Ti-10H
I AAA-$LE DATES z
1 cues0
DATE
3-27-58
;.M,l .AIIuo[o ".E .TCUau . .a
[.au . .
r . .
CARIES, DENTAL DISEASE . MISSING TEETH, ABNORMALITIES 11
DENTAL TREATMENT ACCOMPLISHED
;"°unvrrrrrrr~rr~aw~.
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RENTAL EXAMINATION
Illnf.
AND TREATIQT RECORD .. ..c ..[[ ", (u+. =_ee)
[C-e . ...s)
DONABEDIAN E%HIBIT NO. 1-Continued
w7
TO-0
e .
R.T. Nrdl Penn SOEMT.PN0010 Iid1953
DT DuIwU I I11D U SPICiTcvlal A~2 1RAT .
HEALTH RECORD
DENTAL
SECTION I, DENTAL EXAMINATION1 . PURPOSE OF EXAMINATION
. I 2. TYPE
I INITIA L I
I SEPARATION 1
OTHER (SpECIIT)
1
2
3
A
".
MISSING TEETH AND EXISTING RESTORATIONS
2 3 4 5 6 7 8 9 10 11 12 13 14
31
30
29 28 27 26 25 24 23 22 21 2
19
15
%~r1r~r~rrrr~rran~I
n~rr~rrrrrrr
E.
INDICATE X-RAYS USED IN THIS EXAMINATION
FULL MOUTHPERIAPICAL
DATE
SECTION 11 .
PATIENT DAYA
CE . QF_EX~MI NATI ON
.. .E.
1 , RAE11 .. GRADE RATING OR IDUTIO.
_x I cam.
"TIII . PATIENT'[ LAST HARE-FIRST RAN[-DIDDLI RAN.
OSWALD, LEB RLNJ
POSTERIOR
I OTMER(Speel(7I)BITE-WINGS
DISEASES . ABNORMALITIES. AND X.RAYSI A.
2
~ ~~1~ ~~~Iu,u
.~. m,...~,u. ~
V®J©0~~~" q3 4 5 6 7 8 9 10 11 12 13 14 15S 1
0MG 32
31
30
29 28 27 26 25 24 23 22 21 20
19
18
17
REMARKS ~ !
/ IG i¢E Tr i~L
. ~E
MD1Y
1001'x . ~a
L
DATE
SIGNATURE O. DENTIST COMPLETING "IS SECTION
CALCULUSI SLIGHT I
I MODERATE I
I
HEAVY
S. PERIODONTOCLASI
LOCAL
I IGENERAL
A
INCIPIENT
MODERATE I
ISEVERE
C. STOMATITIS (SINECI(YI
D.
DENTURES NEEDED(Iwelnde deRRIro Needed D(- IRdicamd --I-)
ABNORMALITIES OF OCCLUSION-REMARK{
SIGNATURE Or PERTIET CO0PLETIN0 TNIt, .ECT10.
D. .. ...lunox UNIT
10, -FOREST 01 uANCx
1 . unw.. Den., oR AGERn
i U1340 r13 . DATE OF .IRTN (PAT-RORTN .TOI)
18 OCT.1939
DONABEDIAN EXHIBIT No . 1-Continued
~?o~ a
3. DENTAL CLASSIFICATION
I= 1-1-Is-
I GINGIVITIS
I
I VINCENT'S
FULL I PARTIAL
1E. IDENTIFICATION R
Ex
1653230
D
DENTALs...+a.ra r rmos
SECTION III . ATTENDANCE RECORD
IS . RESTORATIONS AND TREATMENTS (C-rletel 11"i'l e<rvlce)
REMARKS
17 . SERVICES RENDERED
IB . SUBSEQUENT DISEASES AND ABNORMALITIES
Iirl"EvIuw,2 7 4
To Owl 12131411
>D
H 26 27 H !e 24 23 22 21
20
19
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7 . e e 7 e 0 a 11 12 13 1+ 15 1671
10
79 H 27 26 25 24 22 22 21 M
I1
so
11
REMARKS
~ . e . wnmueTr~nnlle ana~
n-eme.at
DONABEDIAN ExnIBIT No . 1-Oontinued
DATE DIAGNOSIS-TREATMENT~, )"Aiucs-if-~~R:ir-MOp.RsK-r-_
CLASS
-_
OPERATOY ENT EACILIT _
_
JIRI- Tuts -
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aN11
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DONABEDIAN E%WHIT No . 1-Continued
~-..l fl-To . a--Os offt-
r.t1 . Ipea~LW-f
bof.~ta "dt.eaitTbof.tt rLq*""'W a".t.wLN.41=La- it.1yy.y .ab)W.al RL.
.f tb fellorlnl fatter.
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.r b I9p Lariq W1oh i1aWLfIUa
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LAv
DONABEDIAN E$HIBIT NO . 1-Oontinued
Standard Pbrm RR" (Rev. Aug. 1961)FBOYU..... er
" DDB.A U Or THE L'UDDevCIICVLAz A-3N hs
IS EXAMINING FACILITY OR EXAMINER . AND ADDRESS
AFES, Dallas, Texas
b_AORT OF MEDICAL EXAMINATION
14. OTHER INFORMATION
Relig : Protestant17. RATING OR SPECIALTY
TIME IN Turn CAPACITY, TOTAL LAST SIX MONYM
CLINICAL EVALUATION
IL HEAD, FACE NECK AND SCALP
19. NOSE
20. SINUSES
21 . MOUTH AND THROAT
uEARS-GENERAL1~'~w~vea'°°nn4)rD1A 71)ndn<i. . . s~d
U. DRUMS (7trfmolbn)
U . EYES-GENERALYVwd a~~l . .bnF.mwaAu... u, eo,.w sn
23. OPHTHALMOSCOPIC
ZE PUPILS (E4u.lil, and readlon)
3L SINE OTHER MUSCULOSKELETAL
39. IDENTIFYING SDDY MARK_ $CARS. TATTOOS
10. SKIN. LYMPHATICS
41. NEUROLOGIC IdeW~nA4~am 79)
47. PSYCHIATRIC u, .u&-.P.n.eru.d ea..i
nW.rnF .6nor
liy
d.!
.
esrprein .nt raNOT
m num
b.lor. rOwmm.nt : wntlnw In Nam 7! andu mddJfMmI.Nwa lf e .o ..wnl
wonlyVI
rmAAaedone)
43 . PELVIC
o VAGRAL
El RECTAL
(Cenldntr. do d
1
2
3
I
S
E
7 ' E
9
ID
11
12
13
14
IS
19 LE
X 31 30 29 7! 27 25 25 24 23 22 21 20 19 14 17FT
IgR,IAL BNOR-
ac Wem m .pPropn.N col-rer "N . E. L ' i1 not ev.luetsd)MA c
-X
x
_x
_X
_x
_z
_X
x
.rnalr
4L DENTAL (FUN applaprtolt enlbdr ab9.1 a bdao umber .J Uppff BadI~ttdA, rerprlia1,)
olpator.Mt IMA
R.-a
.
(dXa).-Flied brWo, baekeft b
I.-NaNed.r.Nt bNA
~X_=.
br dndaro
indUde .Aalmtnt.
RIGNT
43. URRIALYSS : SP. GR
1.018
ALBUMIN A!W MICROSCOPIC
N N ND
AL as
a. ROOD TYPE AND RNFACTOR
ND
9a OTHER TEEN
LAEoulm 1111111111110
11. CHEST X.RAT (Floes.&4 )um "n.W, rsPrn
1 47. mom (19pw6r blf wad dowmom
y:' .¬ , ' :
'T ; . Cr' :U . . .JID
.
ND
DONABEDIAN ExHIBIT No. 1-0ontinued
am 73)
REMARKS AND ADDRIDXAL DENTAL DEFECT ANDDISEASES
ACC
T.-art
L LAST NAME-FIRST NAME-MIDDLE NAME L GRADE AND COMPONENT ON l09IT1O1 L IDENT6ICIITIM 110.
C6wAL0, Lee Harvey APP USMC i4. HOME ADDRESS (NUnlber, rba! v RFD,a, w taoa, ~.nd J3ble) L PURPOSE OF EXAMINATION L WTE M EXAMf101TXBT
4936 Collinwood St, Ft Worth, Tax enlistment USMC 24 Oct 567. SIX L RACE 9. TOTAL YRA GOVT. SERVICE 10. DEPARTMENT, AGENCY, OR SERVICE I1 . ORGANRATI011 UNIT
male Cauc MILITARY CIVIuAN Tal1,A6
IL DATE OF BIRTH 13. PLACE OF BIRTH 14. NAML RELATIONSHIP. AND ADDRESS OF NEXT OF KO -
18 Oct 39 Few Orleans, La MarsIerite Oswald Mother Sam e as
x n. OCULAR Monurr �"�~';',`p-W°I ""' 39 : No marks, ANT.a 2L LUNGS AND CHEST (Indude breadr)
z 29. HEART (T%ru" , rim, TA,am, -Jr) POST : pm rt . scapular; sj" It hand; raulaix 30. VASCULAR SYSTEM (vriruulet, eb .) ops 3" It mastoid.X 31 . ABDOMEN AND VISCERA (Indudt Aamb)
z32. ANUS AND RECTUM
33. ENDOCRINE SYSTEM
34 . G-1 SYSTEM
3L UPPER EXTREMITIES
3E. FEET
37. LOWER EXTREMITIES tgti � �,yreJmel~) X/18 . Mastoid operation 194 I\VY
n.NOTES (CU11E1RRd) AND SIMFIEANT OR INTERVAL HISTORY
71L MRRMART OF WE1CTS AND DIAGOOM MW 4111FINIPS Irq Rem NBMASra)
7L RFOOMMENDATIOMS-fURTHER SPECIALIST EXAMINATIONS INDICATED (BPWVF)
MUSYNEAIENT7 AND OTHER FIN01NO
1 fn .
uJ0
..u
T*
;
: rO .Trl-
flT .a
(vmddlbWA.tb a V1.1% poper AF am"
IA - wP~.B.Rr Pmmwwas
1HIyh1
DONABEDIAN EXHIRIT No. 1-Oontinued
76.
PHYSICAL PRWTIE
51 . HEIGHT SL WEIGHT Sl. COLOR HAIR SI. COLOR EYES SB . BUILD: %.TEMP .
68 131 brown blue SLENDER MEDIUM HEAVY OBE
s)8 .651. BROOD PRESSURE (Arm at Amr1 bet) Ss. PULSE (Arm W Mart lied)
r~ 'YS. SYB. SITTING AFTER EXERCISE I MIN. AFTER - RECUMBENT AFTER STANDING
SITTINGSYS. 12O RECUM"
BENTSTANDING(A ma.) ND ND ND
S MIIL.ND
DIAS. DIAS . As.
B. DISTANT VISION W. RETRACTION - 61 . AFAR VISION
RIGHT m/ 2* CORK TO M/ BY S. CX CORN. TO BY
LEFT m/ 2n CORK TO A/ BY SND CX ]ND CORN TO !Y
P B L N E S
1 1 1 1 ~ 171. EXAMINEE (QHTA) -
"tit &ACT DUTY AT SEA OR ON FOREIGN SBRVIfIT PrtsluILaTEOOR`r
7L W NOT QUALIFIED. LIST DIsouAuPYlno DEFEcTs BV rrE* NUMBER 7 D E
7R. TYPED OR PRINTED NAME OF PHYSICIAN
A . P . BRATRUDE, LT NCUSNR
'
OIL TYPED OR PRINTED MANE OF PHYSICIAN SIGNATURE
BI . TYPED OItMINTEDNAMEOFDENTISTORPHYSICIAN (fdIRN .dkA) SIGNATURE ' . . . j .1. . .
IL TYPED opt PRINTED NAME OF REVIEwma OFFICER OR APPROVING AuTHOItrYY SIGNATURE NUMED Y77
"" MaRAlTd tbrtW M
P .. .ILOAT.u .T
"B_.AD or THE B-
C-UL..A-w - i
IL EXAMINING FACRTY OR UAMwEIL AND ADDRESS
IL O1MEN IIINIIMATMw
AFTSE MLLASN T T:%AS_ _
RP:LE Lutheran17 . STATEMENT OF EXAMINEE'S FRESEAT XGLTH w OWII NORDS. (F.Q .N hRegIpbR awl AIWs,, MromybIM a1Y41
REPORT OF MEDICAL HISTORYTHIS INFORMATION R FOR OFFICIAL .E ONLY ENO WILL MOT R REUASM TO MIIEETHOINUM PERSON
JL"L(./L(./
DoNABEDIAN EXHIBIT No . 1-Oontinued
1 . LAST NAME-FIRST NAME-MOOD NAME 2. GRADE AND COMPONENT OR POET10R E, :jjj=0L= lA "t
AL HOME ADDRESS (N-W,MMfR RFD, CIP IN fNNFE. N RM .YM NW) L NRPM WE" IINTION R. DATE OF
r. VIA) k1( Texas Enlistment OCT Z4EAY-TIM
7. u L NAf: P. TOTAL TAR. QOYT . S"VNa 10. DUARTMENT. AGUPLT.0M SERVICE II . ollweuTMw 11"
A":1~ P Calm ,IIRRTARY OVUM0 U$1v~
IL DATEaI'm IS. :a WITH TL MMC RELATIONSHIP.AND
ADDRESS apEXr a KIM493's, Collinruod St .,
1f1 Dct ,, i Mar erite =ALD 1,i0TIER Fort Worth Texas
"IM. FAMILY H ISTOAY ~- 11.MANASANTMl00DRELATION (PYFeRf, .YWAT, .1 .10M..YG(W)
NOSRANOO)R W)FE. .RFUTIO1f
I® " " " " "
~©~® MFLTION(S)
FATNEN
MOTHER
_y1'~
BROTHERS ra HAD KIDNEY TROURILE IAND HAD HEART
TqOkMLr
imonmHAD
STOMACH TROUBLE
MD NNCUMATISM (AMAYMY)
CMILDNfl1
A. MAYE YOU EVER HAD ON HAVE YCQ NOW (PbH t4.1- of IYO FJrod MY .) - -RS
"
"
(CheCA ..ehitem)
'TRICK" OR LOCKED KNEE
" "T TROVINE
I ~IEURITIS
I PANALYSIS (IR..ft/..R.)SHORTNESS
Of DREATH "UIERLEPSY OR FITS
PAIN OR PPIMUK IN CHEST GR. TRAIN, SEA, OR AIR SICKNESS .
"®p,, FREQUENT TROU%"E SLEEPING
"®- f4i FREwuN OR _IKDMN-
DEPRESSION OR EXCESSIVE WORRY
CRAMPS 1. YOUR LEGs "0 LOSS OF MEMORY OR AMNESIA
.® ~ ~ PIED WETTING- - -XERVWS TROUBLE Of ANY SORT
"gp,~~ANY DRUG OR NARCOTIC HAW
:FA® " . :fEXCESSIVE GRINNING HAW
HIOMOSEXUALTENDFNCIES
H. LAVE You EVEN(Ch-A . .eh item)_ FEMALES OILY- A. NAVE YOU EVER- B. COMPLETE THE FOLLOWING:." RUN PREGNANT AGE AT ONSET OF MENSTRUATION
MA. A VAGDIAL DISCHARGE I _ D1TEMVALBEDPERIODS
_C~ " .~ "" EmITIE1TmFp1AYDNlE WMTIOMOFPERIODS
EV R1. "" "", MD MOMTB"TM DATE OFLAST PUIOD
ilr MDDIIIEFULAMMEI6IRWTE011 wIARFIT"/ : . , .IM.,.
-n. wWMAIDAoo NuYE wniMST71111QTEAMw
y~I4A<~
I -to wlui n THE o VDD
MO~YaTNOE ~tf. AT 0v"awLoom"Tnw
All�~
III!, ARE TOM (Ch ." ar)
_N_ O__
110
CHECK EACH RIM YES OR NO.
V. HAVE YOU BEEN UNABLE TO HOLD A JOB BECAUSE OF,
A. SENSITIVITY TOCMMICALS.DUST,SUMLIGHY,ETC,
" INABILITY TO PERFORM CERTAIN MOTIONS
G INABIL IT TO ASSUME CE TAM POSITIONS
I I
D . OTHER MED1CALRU1ORS(lfY*8v#iv*rP*&*ns)
1EL HAVE 1TlU EVER Wg1RED MIT. MDIWRIVF 3M
lV
STANCE,
b. DID YOU NAK DIFFICULTY WIT" SCHOOL STUDIESOR TEACHERS, (//7- . /ire deteill)
Bl NAVEYOUEVERKENRENSEDEMPIOYMENTBECAUKOF YOUR HEALTH, (1I7-, aANrPewn end /iredaeil.)
TI . HAVE YOU EVER BEEN DENIED LIFE INSURANCE',.
(III... oter. r-oon end giro davit.)
M HAVE YOU HAD, OR NAVE YOU BEEN ADVISED TO HAVE .ANY OPERATIONS' (11 )se, dPwribe end /iree/. .t N,hkh __d)
u. HAVE YOU EVER BEEN A PATIENT (cpm
itted orcolon-l) IN A MENTAL HOSPITAL OM SANATOR .0R, (117-, PJ»cil7 When, Wh .", Hrh7, And
oI dxtor, end xmpl- Add-RA p1hwpitel- clinic)
TB. HAVE YOU EVER HAD ANY ILLNESS OR INJURY OTHERTHAN THOSE AL. OY NOTED: ~ll J-, Ppocil7who., .here, end/% dHUI.)
7E. HAVE YOU CONSULTED OR BE N TREATED BY CLINICS.PHYSICIANS. HEAIERS. ON OTHER PRACTITIONERSWITHIN THE PAST B YEARS, (11 lee. /ire -pl.teeddre f dxt-, h-pit .l. clink .And detell.)
SA HAVE YOUTREATED
YOURSELPMRILLMESSESOTHERTHAN MINOR COLESI (11 ea, Which ill-1)
E) . HAVE YOU EVER KEN REJECTED FOR MILITARYSERVICE KCAUSE OF PHYSICAL MENTAL OR OTHERREASONS' (11TPA, giro deb end r-wn 1-
IL HAVE YOU EVER BEEN DISCHARGED FROM MILITARYSERVICE BECAUSE OF PHYSICAL MENTAL OR OTHERREASONS, (f1 le.. /irP date, r
And
J othP thenH hpnore6h,lprtunAtnP-owen-mihbilitl)
E!. HAVE YW EVER RECEIVED. IS THERE PENDING, HAVEYOU APPLIED FOR.OR DO YOU INTEND YO APPLY FORYEMSKIN OR ODMPENSATION FOR EI(ISTING DISABILMt (fII.., .p.cif7J.h,lAind,/'AntedbyWhpm, .nd whet em. . .t, Whon, Why)
EVERY ITEM CHECKED "'RE'* MUST K RELY EXPLAINED 111 BLANK SPACE OR RIBNTYES
1 CERTIFY THAT I HAVE REVIEWED THE MREWMG IMMRMATNNH SUPPIllb BY ME AND THAT R IS TRUE AND COMPLETE TO THE BEST Of MY KNOWLEDGEI AUTHORISE ANY OF THE DOCTORS. HOSPITALS, 011 CLINICS MENTIONED ABOVE TO --IS- THE GOVEMMENT A COMPLETE TIUNSCIHPr Or MT MEDICAL RECORD FOR PURPOSES
Dr PLgCESLnG MY APPIJCJITION FOR THIS EMPLOYMENT OR SERVICE
/~
TYRO 011 PR11rrm MME or 'NY7AM o11
"Am-
-d
Hit I
" ,
.. SaNAT1ft
:, A. P.,BRATRUDS, LT MC USX.
24 Dot 56
DONABEDIAN EXHIBIT NO. 1-UOIItinlled
NUMBER OF ARA00f"ETS
M)-BKIB "E aEB0FaB1~RAlAtBIrIQ :K~-OiIOBB