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6. Distant vision: This must be obtained by testing with Snellen Vision Chart at 20-foot distance and recorded
as a fraction, the numerator of which is the distance and the denominator the line on the
chart read at 20 feet.
S
Right eye 20/20 - ,
(Right eye 20/
Without glasses
With glasses, if worn
Left eye 20/20- ,
Left eye 20/
7. Ears and Hearing: Do you have a perforated ear drum?
no
Do you have any impairment of hearing? Yes:
No
If so, specify degree-Slight
Moderate
Marked
at
8. Teeth: Gums
Good
Cavities
9 (How many)
(Condition)
filled
Indicate on the chart below, the following conditions:
Missing teeth by X
Bridge work by
Plate-write out the word "plate" and indicate whether upper or lower
Your right
Your left
Cl
Upper X 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Upper
Lower 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 x Lower
9. Date of immunization against Smallpox
1940
Typhoid 1939
Have you been immunized against Tetanus ? no yes When 1939
"
Diphtheria? yes
1939
"
Scarlet fever? yrs
1939
Date and result of last Schick test
Negative
Positive
C
Date and result of last Dick test
Negative
Positive
M
10. What is your present physical condition?
Good
1
If any disabilities, please specify
7-25-42
Marian Hilson
(Date)
(Signature)
It
U
This form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for
enrollment.
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"ocrText": "6. Distant vision: This must be obtained by testing with Snellen Vision Chart at 20-foot distance and recorded\nas a fraction, the numerator of which is the distance and the denominator the line on the\nchart read at 20 feet.\nS\nRight eye 20/20 - ,\n(Right eye 20/\nWithout glasses\nWith glasses, if worn\nLeft eye 20/20- ,\nLeft eye 20/\n7. Ears and Hearing: Do you have a perforated ear drum?\nno\nDo you have any impairment of hearing? Yes:\nNo\nIf so, specify degree-Slight\nModerate\nMarked\nat\n8. Teeth: Gums\nGood\nCavities\n9 (How many)\n(Condition)\nfilled\nIndicate on the chart below, the following conditions:\nMissing teeth by X\nBridge work by\nPlate-write out the word \"plate\" and indicate whether upper or lower\nYour right\nYour left\nCl\nUpper X 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Upper\nLower 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 x Lower\n9. Date of immunization against Smallpox\n1940\nTyphoid 1939\nHave you been immunized against Tetanus ? no yes When 1939\n\"\nDiphtheria? yes\n1939\n\"\nScarlet fever? yrs\n1939\nDate and result of last Schick test\nNegative\nPositive\nC\nDate and result of last Dick test\nNegative\nPositive\nM\n10. What is your present physical condition?\nGood\n1\nIf any disabilities, please specify\n7-25-42\nMarian Hilson\n(Date)\n(Signature)\nIt\nU\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment."
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