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D M R 29
THE AMERICAN RED CROSS
DEPARTMENT OF NURSING
SOUTHERN DIVISION
PHYSICAL EXAMINATION
[Be sure that all questions are answered and that statements zare definite.]
1.
Addresse Name of Phyfactor applicant Spring Beaucharm City Bex308
State ala
2. Age (in years)
Height (in inches) 65 Weight (in pounds) 110
3. General physique
Will nairished
4. Tendency to disease, inherited or otherwise
No
5. Previous history in regard to serious illness or surgical operation
Nine
in
Has she had rheumatism ?
IV
e
6.
7. Has she at present or has she ever had hernia?
Nu
8. Condition of teeth gendre No. molars missing Name No. incisors missing None
Opposed molars
Plates Nasa Crowns None
9.
Condition (State whether of feet flat foot exists and whether
any inconvenience exists).
10. Abdomen and contained organs
Normal
11. Chest and contained organs
Normal
(Chest measurements should be in inches).
Girth; expiration
28
inches; inspiration
31
inches
Respiration, rate of
18
Heart, pulse rate
78
Right eye (Snellen) 20 201
; corrected to 20 20
; lens used
12. Vision:
Left eye (Snellen) 20
; corrected to 20 go
; lens used
(Vision should be determined on proper letters for 20 ft. distance as 20/20, 20/30, etc.)
13. Hearing: A. D. 1/35
A. S. 163-5
(Hearing should record whispered voice at 15 ft., as 15/15, 10/15, etc.)
14. Urine examination:
Color Binlin
Specific gravity
1022
Reaction stiffants
Albumen
None
Nagatina
Casts
Leucocytes
Sugar
15. Do you recommend applicant for:
Night
C
(a) General hospital service
agare
(b) Tropical service
yes
16. Fill in name and number of base hospital, unit or detachment with which applicant is con-
nected:
Army base hospital
Emergency base detachment hospital M 5
Naval
3
D
Navy detachment.
2
Hospital unit
R.M.
Address Shaffeld will accepted at headquarters.
Morgan M. D.
8
Date
All questions MUST be answered; otherwise certificate not/be
To be forwarded to nearest Local Committee or Division Office.
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"ocrText": "D M R 29\nTHE AMERICAN RED CROSS\nDEPARTMENT OF NURSING\nSOUTHERN DIVISION\nPHYSICAL EXAMINATION\n[Be sure that all questions are answered and that statements zare definite.]\n1.\nAddresse Name of Phyfactor applicant Spring Beaucharm City Bex308\nState ala\n2. Age (in years)\nHeight (in inches) 65 Weight (in pounds) 110\n3. General physique\nWill nairished\n4. Tendency to disease, inherited or otherwise\nNo\n5. Previous history in regard to serious illness or surgical operation\nNine\nin\nHas she had rheumatism ?\nIV\ne\n6.\n7. Has she at present or has she ever had hernia?\nNu\n8. Condition of teeth gendre No. molars missing Name No. incisors missing None\nOpposed molars\nPlates Nasa Crowns None\n9.\nCondition (State whether of feet flat foot exists and whether\nany inconvenience exists).\n10. Abdomen and contained organs\nNormal\n11. Chest and contained organs\nNormal\n(Chest measurements should be in inches).\nGirth; expiration\n28\ninches; inspiration\n31\ninches\nRespiration, rate of\n18\nHeart, pulse rate\n78\nRight eye (Snellen) 20 201\n; corrected to 20 20\n; lens used\n12. Vision:\nLeft eye (Snellen) 20\n; corrected to 20 go\n; lens used\n(Vision should be determined on proper letters for 20 ft. distance as 20/20, 20/30, etc.)\n13. Hearing: A. D. 1/35\nA. S. 163-5\n(Hearing should record whispered voice at 15 ft., as 15/15, 10/15, etc.)\n14. Urine examination:\nColor Binlin\nSpecific gravity\n1022\nReaction stiffants\nAlbumen\nNone\nNagatina\nCasts\nLeucocytes\nSugar\n15. Do you recommend applicant for:\nNight\nC\n(a) General hospital service\nagare\n(b) Tropical service\nyes\n16. Fill in name and number of base hospital, unit or detachment with which applicant is con-\nnected:\nArmy base hospital\nEmergency base detachment hospital M 5\nNaval\n3\nD\nNavy detachment.\n2\nHospital unit\nR.M.\nAddress Shaffeld will accepted at headquarters.\nMorgan M. D.\n8\nDate\nAll questions MUST be answered; otherwise certificate not/be\nTo be forwarded to nearest Local Committee or Division Office."
}