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Student
Reserve,
Form 1193
Rev. March 1942
AMERICAN RED CROSS
Report of Physical Condition of Nurse
(Please answer all questions completely and accurately)
Applicant can answer all questions herself, except number 6, with which she will need assistance.
1. Name
Koopman
Betty
Jean
(Last)
(First)
(Middle)
F22
2. 23
Age
Height 5'4/2 inches
Weight 175 pounds
3. Family history Indicate, in the space opposite the disease, which member of your family, if any, has had
the following, and when. Cross out those which no one has had.
Tuberculosis
Were you a contact?
Cancer Father Diabetes
Heart disease
Epilepsy
Mental illness
4. Past medical history : General health
Good
Operations-specify nature of, and Taxe llectomen 1936
year
Appendee tomy 1942
Injuries-specify
Fracture - Loft wrist
Illnesses-cross out the ones which you have not had. Indicate the dates when you had the others :
Allergic conditions
Arthritis
Cancer
Communicable diseases (specify) Chickenpot 1933 Measles 1930 Pertussis
1927
Diabetes
Hay fever
Heart disease...
Hypertension
Migraine
Nervous or mental
Rheumatic fever
Sinusitis
Have you ever had Pulmonary Tuberculosis If so, when
Where did you cure?
Is the condition now arrested?
Have you ever had a suspected
Pulmonary Tuberculosis
If so, when
Others-specify
5. General physique-cross out those which do not apply.
Frail
Good
Robust
Thin
Siender
Obese
OVER
Page data
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- Source index
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- Type
- photo
- Media ID
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- Size
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Document data
- ID
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- Core
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- Type
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Context sent to Scholar
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"ocrText": "Student\nReserve,\nForm 1193\nRev. March 1942\nAMERICAN RED CROSS\nReport of Physical Condition of Nurse\n(Please answer all questions completely and accurately)\nApplicant can answer all questions herself, except number 6, with which she will need assistance.\n1. Name\nKoopman\nBetty\nJean\n(Last)\n(First)\n(Middle)\nF22\n2. 23\nAge\nHeight 5'4/2 inches\nWeight 175 pounds\n3. Family history Indicate, in the space opposite the disease, which member of your family, if any, has had\nthe following, and when. Cross out those which no one has had.\nTuberculosis\nWere you a contact?\nCancer Father Diabetes\nHeart disease\nEpilepsy\nMental illness\n4. Past medical history : General health\nGood\nOperations-specify nature of, and Taxe llectomen 1936\nyear\nAppendee tomy 1942\nInjuries-specify\nFracture - Loft wrist\nIllnesses-cross out the ones which you have not had. Indicate the dates when you had the others :\nAllergic conditions\nArthritis\nCancer\nCommunicable diseases (specify) Chickenpot 1933 Measles 1930 Pertussis\n1927\nDiabetes\nHay fever\nHeart disease...\nHypertension\nMigraine\nNervous or mental\nRheumatic fever\nSinusitis\nHave you ever had Pulmonary Tuberculosis If so, when\nWhere did you cure?\nIs the condition now arrested?\nHave you ever had a suspected\nPulmonary Tuberculosis\nIf so, when\nOthers-specify\n5. General physique-cross out those which do not apply.\nFrail\nGood\nRobust\nThin\nSiender\nObese\nOVER"
}