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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

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Document source extras
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Page context
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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"
}