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D M R 29
THE AMERICAN RED CROSS
DEPARTMENT OF NURSING
Physical Examination
1. Name of applicant Mary ny Story
Address
30 Hortense Street
City Rochester
State ny
2. Age
27yr
Height 62 m
Weight 1083/4/16 (lighted
3. General physique Good
4. Tendency to disease, inherited or otherwise Know of none
5. Previous history in regard to serious illness or surgical operation Sement / was with reppention
at 8 yr
6. Has she had rheumatism ? no
7. Has she at present or has she ever had hernia ? no
8.
Condition of teeth Good - Once upfer rt + once affect. morton musicing
9. Condition of feet Sight femention 2 the inconvening
10. Abdomen and contained organs no Enlargement massive L ten dereless
11. Chest and contained organs no abuaruisities
B
Girth; expiration 28.
inches; inspiration 3014
inches
Respiration, rate of 18
Heart, pulse rate 72
Right eye (Snellen) 9/10
corrected to
; lens used
12. Vision :
Left eye (Snellen) 9/10
corrected to
; lens used
13. Hearing: A. D. O.K. 12/12
A. S. O.K. 12/12
14. Urine examination:
Color Clear normal yellow
Reaction Barely acid
Specific gravity 1018
Albumen Possible trave
Casts none
Leucocytes Very few
Sugar none
15. Do you recommend applicant for:
(a) General hospital service yes
(b) Tropical service
16. Fill in name and number of base hospital, unit or detachment with which applicant is connected
:
Army base hospital
Naval base hospital
Emergency detachment
Navy detachment
Hospital unit
Lucium L. Bulton
M. D.
Date august 1 1925
Address 265 alexander street
All questions MUST be answered; otherwise certificate will not be accepted at head-
quarters.
To be forwarded to Chief Nurse of Unit or to the Local Committee on Red Cross
Nursing Service.
(SEE OTHER SIDE)
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"ocrText": "D M R 29\nTHE AMERICAN RED CROSS\nDEPARTMENT OF NURSING\nPhysical Examination\n1. Name of applicant Mary ny Story\nAddress\n30 Hortense Street\nCity Rochester\nState ny\n2. Age\n27yr\nHeight 62 m\nWeight 1083/4/16 (lighted\n3. General physique Good\n4. Tendency to disease, inherited or otherwise Know of none\n5. Previous history in regard to serious illness or surgical operation Sement / was with reppention\nat 8 yr\n6. Has she had rheumatism ? no\n7. Has she at present or has she ever had hernia ? no\n8.\nCondition of teeth Good - Once upfer rt + once affect. morton musicing\n9. Condition of feet Sight femention 2 the inconvening\n10. Abdomen and contained organs no Enlargement massive L ten dereless\n11. Chest and contained organs no abuaruisities\nB\nGirth; expiration 28.\ninches; inspiration 3014\ninches\nRespiration, rate of 18\nHeart, pulse rate 72\nRight eye (Snellen) 9/10\ncorrected to\n; lens used\n12. Vision :\nLeft eye (Snellen) 9/10\ncorrected to\n; lens used\n13. Hearing: A. D. O.K. 12/12\nA. S. O.K. 12/12\n14. Urine examination:\nColor Clear normal yellow\nReaction Barely acid\nSpecific gravity 1018\nAlbumen Possible trave\nCasts none\nLeucocytes Very few\nSugar none\n15. Do you recommend applicant for:\n(a) General hospital service yes\n(b) Tropical service\n16. Fill in name and number of base hospital, unit or detachment with which applicant is connected\n:\nArmy base hospital\nNaval base hospital\nEmergency detachment\nNavy detachment\nHospital unit\nLucium L. Bulton\nM. D.\nDate august 1 1925\nAddress 265 alexander street\nAll questions MUST be answered; otherwise certificate will not be accepted at head-\nquarters.\nTo be forwarded to Chief Nurse of Unit or to the Local Committee on Red Cross\nNursing Service.\n(SEE OTHER SIDE)"
}