MEDICAL REPORT ON AN INVALID
(Taken from Army Form B 179)
8. Disability
STATEMENT OF CASENote.—The answers to the following questions are to be filled in by the officer in medical charge of the case. In answering them he will carefully discriminate between the man's unsupported statements and evidence recorded in his military and medical documents. He will also carefully distinguish cases entirely due to venereal disease.
9. Date of origin of disability.
10. Place of origin of disability.
11. Give concisely the essential facts of the history of the disability, noting entries on the Medical History Sheet bearing on the case.
12. (a) Give your opinion as to the causation of the disability.
(b) If you consider it to have been caused by active service, climate, or ordinary military service, explain the specific conditions to which you attribute it. (See Notes on p. 71.)
13. What is his present condition?
Weight should be given in all cases when it is likely to afford evidence of the progress of the disability.
14. If the disability is an injury, was it caused—
(a) In action?
(b) On field service?
(c) On duty?
(d) Off duty?15. Was a Court of Inquiry held on the injury?
If so—(a) When?
(b) Where?
(c) Opinion?16. Was an operation performed? If so, what?
17. If not, was an operation advised and declined?
18. In case of loss or decay of teeth. Is the loss of teeth the result of wounds, injury, or disease, directly[6] attributable to active service?
19. Do you recommend—
(a) Discharge as permanently unfit, or
(b) Change to England?————————————
Officer in medical charge of case.I have satisfied myself of the general accuracy of this report, and concur therewith, except[7]
Station————————
Officer in charge of Hospital.
Date————————
FOOTNOTES:
[6] Loss of teeth on, or immediately after, active service, should be attributed thereto, unless there is evidence that it is due to some other cause.
[7] Delete this word if no exceptions are to be made.