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Form 1193
Rev.6-15-25
THE AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(Follow instructions at foot of page in answering all questions)
in
1. Name of applicant Emma maurin
Badge No.
in
2. Age 39
Address La, state Board g Health City new Area State Lu.
a
Height
5 for 4
Weight 118
3. General physique good -
4. Tendency to disease, inherited or otherwise
none
5.
Previous history in regard to serious illness or surgical operation Isa - Appendictory
6. Has she had rheumatism ?
no
7. Has she at present or has she ever had hernia ?
no
8. Condition of teeth
good 3 melasoming
9. Condition of Bones and Joints
normal Flat Foot
no
10. Abdomen and contained organs
normal
B
11. Chest and contained organs
Girth: Expiration 31
negatine
inches. Inspiration 3 3
inches
Respiration, rate of
18
Heart, pulse rate 72
Right eye (Snellen) 30/20
-
Corrected to
-
lens used
12. Vision:
Left eye (Snellen) 20/20
Corrected to
-
lens used
-
13. Hearing: Right 20 eff Whishes
Left
20
20
aft.
14. Urine examination
Color anther
Reaction
hard
Specific gravity
10.10
Albumen
neq.
Casts
none
Leucocytes
Sugar
none
meg.
15. Do you recommend applicant for active hospital service?
yes
R.7 aleman , M.
D.
Date 0/3/27
Address 1407 So. Carroeton
All questions MUST be answered; otherwise certificate will not be accepted at Headquarters.
To be forwarded to the Local Committee on Red Cross Nursing Service.
1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.
2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.
8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.
9. Flat foot-state whether or not any inconvenience exists.
11. Chest measurements should be in total inches.
12. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50, 20-100, etc. If glasses
are worn state correction. Hearing should record whispered voice at 20 feet, as 20-20, 15-20,10-20, etc.
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Document data
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"ocrText": "M\naut\nForm 1193\nRev.6-15-25\nTHE AMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(Follow instructions at foot of page in answering all questions)\nin\n1. Name of applicant Emma maurin\nBadge No.\nin\n2. Age 39\nAddress La, state Board g Health City new Area State Lu.\na\nHeight\n5 for 4\nWeight 118\n3. General physique good -\n4. Tendency to disease, inherited or otherwise\nnone\n5.\nPrevious history in regard to serious illness or surgical operation Isa - Appendictory\n6. Has she had rheumatism ?\nno\n7. Has she at present or has she ever had hernia ?\nno\n8. Condition of teeth\ngood 3 melasoming\n9. Condition of Bones and Joints\nnormal Flat Foot\nno\n10. Abdomen and contained organs\nnormal\nB\n11. Chest and contained organs\nGirth: Expiration 31\nnegatine\ninches. Inspiration 3 3\ninches\nRespiration, rate of\n18\nHeart, pulse rate 72\nRight eye (Snellen) 30/20\n-\nCorrected to\n-\nlens used\n12. Vision:\nLeft eye (Snellen) 20/20\nCorrected to\n-\nlens used\n-\n13. Hearing: Right 20 eff Whishes\nLeft\n20\n20\naft.\n14. Urine examination\nColor anther\nReaction\nhard\nSpecific gravity\n10.10\nAlbumen\nneq.\nCasts\nnone\nLeucocytes\nSugar\nnone\nmeg.\n15. Do you recommend applicant for active hospital service?\nyes\nR.7 aleman , M.\nD.\nDate 0/3/27\nAddress 1407 So. Carroeton\nAll questions MUST be answered; otherwise certificate will not be accepted at Headquarters.\nTo be forwarded to the Local Committee on Red Cross Nursing Service.\n1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.\n2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.\n8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.\n9. Flat foot-state whether or not any inconvenience exists.\n11. Chest measurements should be in total inches.\n12. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50, 20-100, etc. If glasses\nare worn state correction. Hearing should record whispered voice at 20 feet, as 20-20, 15-20,10-20, etc."
}