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FORM 1193
REV. 10-22-36
THE AMERICAN RED CROSS NURSING SERVICE
F
9
11'
S
anes
DM
PHYSICAL EXAMINATION
5
1° 09 spos
a
(Follow instructions at end of form in answering all questions)
fara Sullivan
gerrg-
1. Name of applicant
Address meth Hogp
City Dallas
Texas
State
22
2. Age
Height 5'7' "
Weight
135
OLOMUE
byepes
moig
3. General physique good
4. Tendency to disease, inherited or otherwise
have
5. Previous history in regard to operation, injury or illness Puemonia at 6-7-19y2
magan- honging
6. Vision: Right eye; Distant vision V%/20 Corrected to no Lens used
Left eye; Distant vision VIqu Corrected to no Lens
used
NOTE:-Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
If glasses are worn state correction.
4° /40"
15
7. Hearing: Right ear; Watch
Whispered voice
/15'
40 /40" Whispered voice
15
Left ear; Watch
/15'
8.
Teeth and gums : (note abnormalities) normal
NOTE-Check chart on other side of blank.
would
9. Neck: (Thyroid glands and other abnormalities)
10. Spine and extremities; (bones, joints, muscles and feet)
(voge
OL
nound
11. Thorax: Respiratory system, bronchi, lungs, pleura, etc.
Expiration
2942
inches
Inspiration 32
inches
121
Respiration
16
per minute
for
homel
Cardio-vascular system
Heart: (note all of cardiac involvement) normal
signs
38
srug
Pulse 12 Blood pressure: S 110
D
62
(Over)
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"ocrText": "FORM 1193\nREV. 10-22-36\nTHE AMERICAN RED CROSS NURSING SERVICE\nF\n9\n11'\nS\nanes\nDM\nPHYSICAL EXAMINATION\n5\n1° 09 spos\na\n(Follow instructions at end of form in answering all questions)\nfara Sullivan\ngerrg-\n1. Name of applicant\nAddress meth Hogp\nCity Dallas\nTexas\nState\n22\n2. Age\nHeight 5'7' \"\nWeight\n135\nOLOMUE\nbyepes\nmoig\n3. General physique good\n4. Tendency to disease, inherited or otherwise\nhave\n5. Previous history in regard to operation, injury or illness Puemonia at 6-7-19y2\nmagan- honging\n6. Vision: Right eye; Distant vision V%/20 Corrected to no Lens used\nLeft eye; Distant vision VIqu Corrected to no Lens\nused\nNOTE:-Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\nIf glasses are worn state correction.\n4° /40\"\n15\n7. Hearing: Right ear; Watch\nWhispered voice\n/15'\n40 /40\" Whispered voice\n15\nLeft ear; Watch\n/15'\n8.\nTeeth and gums : (note abnormalities) normal\nNOTE-Check chart on other side of blank.\nwould\n9. Neck: (Thyroid glands and other abnormalities)\n10. Spine and extremities; (bones, joints, muscles and feet)\n(voge\nOL\nnound\n11. Thorax: Respiratory system, bronchi, lungs, pleura, etc.\nExpiration\n2942\ninches\nInspiration 32\ninches\n121\nRespiration\n16\nper minute\nfor\nhomel\nCardio-vascular system\nHeart: (note all of cardiac involvement) normal\nsigns\n38\nsrug\nPulse 12 Blood pressure: S 110\nD\n62\n(Over)"
}