3. Use of standard clinical and health record forms—Continued 4. Procurement of forms.-The forms should be procured from the General Services Administration, Federal Supply Service. Regular stock will consist of single sheets printed on both sides if necessary, but they may also be ordered as manifold forms. The date of availability of the new forms will be announced by Federal Supply Service. DAVID E. BELL, Director. BUREAU OF THE BUDGET CIRCULAR A-32 EXECUTIVE OFFICE OF THE PRESIDENT, BUREAU OF THE BUDGET, Washington, D.C., May 17, 1965. CIRCULAR NO. A-32, REVISED TRANSMITTAL MEMORANDUM NO. 1 To: The heads of executive departments and establishments. Subject: Standard forms for medical examination and clinical and health records. This Transmittal Memorandum to Bureau of the Budget Circular No. A-32, as revised May 3, 1962, promulgates the following standard medical examination and clinical and health record forms: Rev. March 1965----- Report of Medical History. 512 A-January 1965____. Clinical Record-Plotting Chart-Blood Pressures. 514 N-Rev. March 1965_. Clinical Record-Blood Bank. Supplies of the above forms are to be procured from the General Services Administration, Federal Supply Service; however, old stocks of the revised forms will be used until they are exhausted. KERMIT GORDON, Director. NO YES NO (B) DOES THE VETERANS ADMINISTRATION RECOGNIZE SERVICE-CONNECTED DISABILITY IN YOUR CASE? YES O HAVE YOU EVER RECEIVED DISABILITY RETIREMENT FROM THE US CIVIL SERVICE COMMISSION? Sign your name in INK as it appears on your appli- SIGNATURE OF APPLICANT cation in the presence of the physician for purpose } of identification. PART B-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 15 and 16 on the Health Qualification Placement Record so that you will have 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. LEFT WITH GLASSES, IF WORN: RIGHT LEFT (A) DISTANT VISION (SNELLEN): WITHOUT GLASSES: 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. (D) COLOR VISION IS COLOR VISION NORMAL WHEN ISHIHARA OR OTHER COLOR PLACE TEST IS USED? YES NO IF NOT. CAN APPLICANT PASS LANTERN, YARN, OR OTHER COMPARABLE TEST? YES NO 3. EARS: (CONSIDER DENOMINATORS INDICATED HERE AS NORMAL. RECORD AS NUMERATORS THE GREATEST DISTANCE HEARD.) ORDINARY CONVERSATION: RIGHT EAR EVIDENCE OF DISEASE OR INJURY: RIGHT EAR LEFT EAR 4. NOSE LEFT EAR 7. GASTRO-INTESTINAL (A) HISTORY OF PEPTIC ULCER: YES NO. IF YES," IS ULCER: ACTIVE QUIESCENT HEALED 8. METABOLIC DISORDERS; (INDICATE ANY ABNORMALITY OF THE FOLLOWING GLANDS BY A CHECK IN THE APPROPRIATE BOX, AND EXPLAIN UNDER "REMARKS.") THYROID PANCREAS PITUITARY OVARIAN (IF X-RAY IS MADE. GIVE REPORT UNDER "REMARKS" BELOW.) 11. HERNIA:YES NO. IF YES," NAME VARIETY: INGUINAL, VENTRAL, FEMORAL, POST-OPERATIVE, ETC.: IF PRESENT, IS IT SUPPORTED BY A WELL-FITTING TRUSST YES NO 12. VARICOSE VEINS: YES NO. IF "YES," STATE LOCATION AND DEGREE 13. FEET: IS FLAT FOOT PRESENT? (GOOD, FAIR, OR POOR) YES NO. IF "YES," GIVE FULL DETAILS. YES NO. IF "YES," STATE DEGREE OF IMPAIRMENT OF FUNCTION (HOME. SLIGHT, MODERATE SEVERE 14. DEFORMITIES, ATROPHIES, AND OTHER ABNORMALITIES, DISEASE NOT INCLUDED ABOVE 15. SCARS OF SERIOUS INJURY OR DISEASE 16. NERVOUS SYSTEM: (A) INCLUDE SYMPTOMS AND FULL HISTORY OF ANY MENTAL, NERVOUS, OR EMOTIONAL ABNORMALITY (USE ADDITIONAL SHEETS IF NECES SARY.): (B) HAS APPLICANT EVER BEEN HOSPITALIZED OR TREATED FOR A MENTAL ILLNESS? YES NO (C) WHERE (NAME AND LOCATION OF HOSPITAL): (D) DATE OR DATES OF HOSPITALIZATION: (E) DESCRIBE ANY RESIDUALS OF PREVIOUS MENTAL OR NERVOUS ILLNESS: (F) ANY HISTORY OF EPILEPSY OR FAINTING SPELLS? YES NO. IF SO, GIVE DETAILS UNDER "REMARKS" BELOW. 17. EVIDENCE OR HISTORY OF VENEREAL DISEASE: IF BLOOD SEROLOGY OR OTHER LABORATORY EXAMINATIONS ARE MADE, GIVE DETAILS UNDER "REMARKS" BELOK |