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S
a
e
1
S
Form 1193
Rev. 6-15-25
THE AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(Follow instructions at foot of page in answering all questions)
1. Name of applicant this Senva undersue Badge
No.
2. Age
Address 30 901 Benery Height St. 5' City 7" Nunah Weight State 126 Was
3. General physique
4. Tendency to disease, inherited or otherwise
5. Previous history in regard to serious 1919 illness or surgical operation affended 1922
6. Has she had rheumatism ? no
tomedicting
7. Has has she had hernia? no
9. Condition of Bones and Joints normal
8.
Condition she at of present teeth or smolars ever out.- - 1Bridge - no
Flat Foot
11. Chest and contained organs normal
10. Abdomen and contained organs negative
Girth Expiration
33
inches. Inspiration
36
inches
Respiration, rate of
18
Heart, pulse rate
80
Right eye (Snellen) 29/08
in
B
Corrected to
zo
lens used
12. Vision:
Left eye (Snellen)
too
30
Corrected to
so JUT lens used
13. Hearing: Right
ago
Left
200
14. Urine examination
Color amber
Reaction alk
1018
Albumen maine
Specific gravity
Casts -a
Leucocytes Jun
Sugar wmee
S do.
15. Do you recommend applicant for active hospital service?
Date 1-16-26
Address M.D.
are Wis;
All questions MUST be answered; otherwise certificate will not be accepted at Headquarters.
To be forwarded to the Local Committee on Red Cross Nursing Service.
1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.
2. Give in height in inches, weight in pounds, stating amount of clothing entering into weight.
8.
State age what teeth years, are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.
9. Flat foot-state whether or not any inconvenience exists.
12. 11. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50,20-100, etc. If glasses
Chest measurements should be in total inches.
are worn state correction. Hearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.
O
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Document data
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"ocrText": "D\nS\na\ne\n1\nS\nForm 1193\nRev. 6-15-25\nTHE AMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(Follow instructions at foot of page in answering all questions)\n1. Name of applicant this Senva undersue Badge\nNo.\n2. Age\nAddress 30 901 Benery Height St. 5' City 7\" Nunah Weight State 126 Was\n3. General physique\n4. Tendency to disease, inherited or otherwise\n5. Previous history in regard to serious 1919 illness or surgical operation affended 1922\n6. Has she had rheumatism ? no\ntomedicting\n7. Has has she had hernia? no\n9. Condition of Bones and Joints normal\n8.\nCondition she at of present teeth or smolars ever out.- - 1Bridge - no\nFlat Foot\n11. Chest and contained organs normal\n10. Abdomen and contained organs negative\nGirth Expiration\n33\ninches. Inspiration\n36\ninches\nRespiration, rate of\n18\nHeart, pulse rate\n80\nRight eye (Snellen) 29/08\nin\nB\nCorrected to\nzo\nlens used\n12. Vision:\nLeft eye (Snellen)\ntoo\n30\nCorrected to\nso JUT lens used\n13. Hearing: Right\nago\nLeft\n200\n14. Urine examination\nColor amber\nReaction alk\n1018\nAlbumen maine\nSpecific gravity\nCasts -a\nLeucocytes Jun\nSugar wmee\nS do.\n15. Do you recommend applicant for active hospital service?\nDate 1-16-26\nAddress M.D.\nare Wis;\nAll questions MUST be answered; otherwise certificate will not be accepted at Headquarters.\nTo be forwarded to the Local Committee on Red Cross Nursing Service.\n1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.\n2. Give in height in inches, weight in pounds, stating amount of clothing entering into weight.\n8.\nState age what teeth years, are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.\n9. Flat foot-state whether or not any inconvenience exists.\n12. 11. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50,20-100, etc. If glasses\nChest measurements should be in total inches.\nare worn state correction. Hearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.\nO"
}