ged by over 10 lb in the last year. Indicate amount and reason 3. Haight 9`'weight no DOB ti_ 1\2.7.f.5) SS ellail_31 3. Name and Address of Perscral Physic! in ,TD • —I) r t), a. Vi c C N%) e, `-{ W. 4, Phone rumber (If known) d. Oats lest seen and reason' 3 IV 3 7-!: o •-•-14 • _ 5. Fautifr