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e
e
6
{
a
FORM 1193
L
er
REV. 10-26-38
AMERICAN RED CROSS NURSING SERVICE
S
to
PHYSICAL EXAMINATION
(Follow instructions at end of form in answering all questions)
law
1. Name of applicant Virginia Robinson
Address 334 Boton Patroad City Weston
State mass
2. Age 29
Height 67's inches
Weight 140's lbs
3. Family history Paternal grandfather died Robility
4. Past history: injury, illnesses
General health, operation, any
appendintonas marry Taa twice
5.
General physique
Eyes: Pupils; Right 312mm eye; Distant vision 20/20 Corrected to
Lens used
6.
L.
Left ese; 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.
M
If glasses are worn state correction. Formuch neor work +75=+ 25X70
7. Ears:
normal
+-75=+.25x90
8. Teeth and gums: (note abnormalities) normal
NOTE:-Check chart on other side of blank.
9. Throat normal
10. Neck: (Thyroid gland and other abnormalities) normal
11. Skeletal: (Bones, joints, muscles and feet) normal
12. Thorax: Expiration
30
inches
Inspiration 34
inches
Respiration 18
per minute
Lungs to percussion and auscultation normal
-baeH Cardio-vascular da system normal
Heart: Size normal
Murmurs none heard
Pulse 80
Blood pressure: S 126
D 80
(Over)
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"ocrText": "ZI\ne\ne\n6\n{\na\nFORM 1193\nL\ner\nREV. 10-26-38\nAMERICAN RED CROSS NURSING SERVICE\nS\nto\nPHYSICAL EXAMINATION\n(Follow instructions at end of form in answering all questions)\nlaw\n1. Name of applicant Virginia Robinson\nAddress 334 Boton Patroad City Weston\nState mass\n2. Age 29\nHeight 67's inches\nWeight 140's lbs\n3. Family history Paternal grandfather died Robility\n4. Past history: injury, illnesses\nGeneral health, operation, any\nappendintonas marry Taa twice\n5.\nGeneral physique\nEyes: Pupils; Right 312mm eye; Distant vision 20/20 Corrected to\nLens used\n6.\nL.\nLeft ese; 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.\nM\nIf glasses are worn state correction. Formuch neor work +75=+ 25X70\n7. Ears:\nnormal\n+-75=+.25x90\n8. Teeth and gums: (note abnormalities) normal\nNOTE:-Check chart on other side of blank.\n9. Throat normal\n10. Neck: (Thyroid gland and other abnormalities) normal\n11. Skeletal: (Bones, joints, muscles and feet) normal\n12. Thorax: Expiration\n30\ninches\nInspiration 34\ninches\nRespiration 18\nper minute\nLungs to percussion and auscultation normal\n-baeH Cardio-vascular da system normal\nHeart: Size normal\nMurmurs none heard\nPulse 80\nBlood pressure: S 126\nD 80\n(Over)"
}