STATEMENT OF HEALTH AND
For use of this form, see AR 145-1; the proponent agency is DCS, G-1.
MEDICAL EXAMINATION
SCHOOL
DATE
I underwent a medical examination in conjunction with enrollment in MS III on or about
at
,
(Date)
(Place)
and to the best of my knowledge and belief there has been no change in my medical condition since the
accomplishment of this medical examination except as noted below: (List changes in medical condition, or
insert "No change", as appropriate.)
(Signature)
APD LC v1.01ES
DA FORM 2453-R, 1 SEP 1961
STATEMENT OF HEALTH AND
For use of this form, see AR 145-1; the proponent agency is DCS, G-1.
MEDICAL EXAMINATION
SCHOOL
DATE
I underwent a medical examination in conjunction with enrollment in MS III on or about
at
,
(Date)
(Place)
and to the best of my knowledge and belief there has been no change in my medical condition since the
accomplishment of this medical examination except as noted below: (List changes in medical condition, or
insert "No change", as appropriate.)
(Signature)
APD LC v1.01ES
DA FORM 2453-R, 1 SEP 1961