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THE AMERICAN RED CROSS NURSING SERVICE
FORM 1193
RÉV. 10-22-36
II
S
PHYSICAL EXAMINATION
1
an
16
(Follow instructions at end of form in answering all questions)
g
M
1. Name of
applicant mary Petronilla Common
Address St. John's Hoop, City At.fours State
missouri
ary
2. Age 31
Height
5ft.3th Weight
116 lbs
3. General physique normal
4. Tendency to disease, inherited or otherwise name
to
5. in to injury or illness name
Previous history regard operation,
Seader Kever 1927
6. Vision: Right eye; Distant vision 20/20 Corrected to
Lens used
P
Left eye; Distant vision 20/20 Corrected to
Lens used
NOTE: Actual vision should be determined on proper letters for 20 foot distant, as 20-20,20-30,20-100, etc.
If glasses are worn state correction.
40/40"
p
7. Hearing: Right ear; Watch
Whispered voice
15/15
Left ear; Watch
40/40"
Whispered voice
15/15
8.
Teeth and gums: (note abnormalities) normal
NOTE-Check chart on other side of blank,
9.
Neck: (Thyroid glands and other abnormalities normal
10. Spine extremities; (bones, joints,
and muscles and feet) normal
11. Thorax: bronchi, lungs, pleura, etc. normal
Respiratory system,
Expiration 30 1/2 inches
Inspiration 31 1/2
inches
if
Respiration
per minute
Cardio-vascular system normal
Heart:
(note all signs of cardiac involvement) normal
I
15
Pulse 80 Blood pressure: S 112 D. 20
(Over)
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"ocrText": "THE AMERICAN RED CROSS NURSING SERVICE\nFORM 1193\nRÉV. 10-22-36\nII\nS\nPHYSICAL EXAMINATION\n1\nan\n16\n(Follow instructions at end of form in answering all questions)\ng\nM\n1. Name of\napplicant mary Petronilla Common\nAddress St. John's Hoop, City At.fours State\nmissouri\nary\n2. Age 31\nHeight\n5ft.3th Weight\n116 lbs\n3. General physique normal\n4. Tendency to disease, inherited or otherwise name\nto\n5. in to injury or illness name\nPrevious history regard operation,\nSeader Kever 1927\n6. Vision: Right eye; Distant vision 20/20 Corrected to\nLens used\nP\nLeft eye; Distant vision 20/20 Corrected to\nLens used\nNOTE: Actual vision should be determined on proper letters for 20 foot distant, as 20-20,20-30,20-100, etc.\nIf glasses are worn state correction.\n40/40\"\np\n7. Hearing: Right ear; Watch\nWhispered voice\n15/15\nLeft ear; Watch\n40/40\"\nWhispered voice\n15/15\n8.\nTeeth and gums: (note abnormalities) normal\nNOTE-Check chart on other side of blank,\n9.\nNeck: (Thyroid glands and other abnormalities normal\n10. Spine extremities; (bones, joints,\nand muscles and feet) normal\n11. Thorax: bronchi, lungs, pleura, etc. normal\nRespiratory system,\nExpiration 30 1/2 inches\nInspiration 31 1/2\ninches\nif\nRespiration\nper minute\nCardio-vascular system normal\nHeart:\n(note all signs of cardiac involvement) normal\nI\n15\nPulse 80 Blood pressure: S 112 D. 20\n(Over)"
}