CSB Form 31 Medical Report

 

  EUJ53 Utbelhm jy Abvt Prkothrs

CPPHOMKT KKK (^kmh Ahohrcf Brmhr ; (c) 

ZHPXJFKE BN WCIJKC NBZI BN EHZ]KNKEC]H BN IHMKECF HTCIKOC]KBO

]b (3) .............................................. .................................................................... ............................................ ............................................ ............................................... ..................................... ............ K dhrhjy ehrtkny ehrtk ny tdct K dcvh tdks mcy hxcikohm (:) ................................................ ...................................................................... ................................ .......... ............................................ ...................... ............................................ ............................................. ............................................. ............................................ ............................................. ........................... .... Ecomkmcth nbr hipfbyihot cs c s (5) ........................................... ................................................................. ............................................ ......................................... ................... ............................................. ...................... ............................................. ............................................ ............................................ ............................................ ............................................. .......................... ... Com ko iy bpkokbo dh/sdh ks (=)............................................. (=)............................................. nbr shrvkeh ko tdh Zhpujfke bn Wcijkc. ......................................................... Ihmkecf Bnnkehr ..........................................Utctkbo ......................................:0...........

(3) ]b tdh Dhcm bn Mhpcrtihot ko edcrah bn ecomkmcth. (:) com (5) tb jh nkffhm ko jy tdh Mhpcrtihot cppfykoa nbr c Ihmkecf Ehrtknkecth. (=) Ihmkecf Bnnkehr tb koshrt —nkt‛ br —uonkt‛ cs tdh ecsh icy jh.  jh.   (8) Zhvhrsh tb jh ebipfhthm bo ebpy nbr MIU bofy.  ]dks nbri icy jh bjtckohm nrbi Mkrhetbr bn Ihmkecf Uhrvkehs, Fusclc.

 

  ]B JH EBIPFH]HM BO EBP[ NBZ MIU BOF[

Cah.................................... Cah.................. .................. Dhkadt......................................... Dhkadt........................................... Qhkadt......................................... Qhkadt................................................... .......... Pdyskquh........................................ Pdyskquh................ .......................................... .................. Ihmkecf Utcth.............................................. Utcth................................................................ .................. Prhvkbus Kffohsshs................................................... Kffohsshs......................................................................... ............................................ ............................................ .................................... .............. ............................................ ...................... ............................................. ............................................. ............................................ ............................................ ............................................ ........................... ..... ZHUPKZC]BZ[ U[U]HI7 Akrtd............... Nuff Kospkrctkbo................... Nuff Hxpkrctkbo..................

Hxcikoctkbo................................................................ ............................................ ......................... ... (c)Coy cjobricfkty bo efkokecf Hxcikoctkbo.......................................... ......................................... ................... ............................................ ............................................ ............................................. ............................................. ............................................ ......................... ...

(j) 

T-rcy bn edhst (wdhrh pbsskjfh) ............................................ .................................................................. ............................................ ............................... .........

ECZMKB ^CUEXFCZ U[U]HI7

(c) Zcth com qucfkty bn pufsh ......................................... ................... ............................................. ............................................. ............................................ ............................ ...... .................................................................... ............................................ ....................................... ................. (j)  Coy ecrmkce cjobricfkty .............................................. .................................................................... ............................................ ............................................. ..................................... .............. (e)  Jfbbm prhssurh .............................................. .................................................................... ............................................. ............................................. ................................ .......... (m)  Coy vcrkebsh vhko .............................................. CFKIHO]CZ[ U[U]HI COM CJMBIHO7

................................................................ ............................................ ............................................ .................................... .............. (c)  Coy syiptbis .......................................... tboskfs................................................................. ............................................ ........................ .. (j)  Ebomktkbo bn ibutd, thhtd com tboskfs........................................... fk vhr br spfhho.................................................. spfhho........................................................................ .......................................... .................... (e)  Coy cjobricfkty bn fkvhr dhrokcs................................................................. ............................................. ............................................. ......................................... ................... (m)  Coy dhrokcs........................................... dchibrrdbkms............................................................ .............................................. .............................................. ...................................... ................ (h)  Coy dchibrrdbkms...................................... AHOK]B-XZKOCZ[ U[U]HI7

cjobricfkty.......................................................... ............................................... .............................................. ..................... (c)  Coy syiptbis br cjobricfkty.................................... Uuacr............................ (j)  Xrkoh................ UA.................... Zhcetkbo................... Cfj....................... Uuacr.......................... KO]HAXIHO]CZ[ U[U]HI7 (c) Coy Coy hruptkbo br ufehr............................................... ufehr...................................................................... ............................................. ............................................ ............................. ....... EOU7

(c) Coy Coy syiptbis..................................... syiptbis........................................................... ............................................ ............................................ ............................................ ............................ ...... (j) Pcthffcr Pcthffcr rhnfhxhs.................................................. rhnfhxhs........................................................................ ............................................ ............................................ .................................... .............. (e) Pupkfs....................................... Pupkfs............................................................. ............................................ ............................................ ............................................ ........................................ .................. (m) Dhcrkoa........................................ Dhcrkoa.............................................................. ............................................. ............................................. ............................................ .................................... .............. (h) Uphhed........................................ Uphhed............................................................... ............................................. ............................................ ............................................ ..................................... ............... ZHICZLU<

............................................ ...................... ............................................. ............................................. ............................................ ............................................ ............................................ ........................... ..... ............................................ ...................... ............................................. ............................................. ............................................ ............................................ ............................................ ........................... ..... ............................................ ...................... ............................................. ............................................. ............................................ ............................................ ............................................ ........................... ..... Mcth7 ................................................ ................................................

..................... ............................................ ............................... ........ Ihmkecf bnnkehr

Utctkbo7 ...................................... ............................................ ......