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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 Namirun
(Last)
junnick
(First)
agner
(Middle)
+ 5 + 28
2. Age 22
Height 67 inches
Weight
190
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 - 1942 Diabetes
Heart disease
Epilepsy_
Mental illness
4. Past medical history : General health Good
Operations-specify nature of, and year more
Injuries-specify none
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) Chicken pox 1928, mealed 1926 1929
Diabetes
Hay fever
Heart disease -
Hypertension-
Migraine-
Nervous or mental
Rheumatic fever
Sinusitis
Have you ever had Pulmonary Tuberculosis ? If so, when
no.
Where did you cure?
Is the condition now arrested?
Have you ever had a suspected
Pulmonary Tuberculosis ? no. If so, when
Others-specify
5. General physique-cross out those which do not apply.
Frail
Good
Robust
Thin
-Slender
Obese
OVER
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- Core
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"ocrText": "Form 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 Namirun\n(Last)\njunnick\n(First)\nagner\n(Middle)\n+ 5 + 28\n2. Age 22\nHeight 67 inches\nWeight\n190\npounds\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 - 1942 Diabetes\nHeart disease\nEpilepsy_\nMental illness\n4. Past medical history : General health Good\nOperations-specify nature of, and year more\nInjuries-specify none\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) Chicken pox 1928, mealed 1926 1929\nDiabetes\nHay fever\nHeart disease -\nHypertension-\nMigraine-\nNervous or mental\nRheumatic fever\nSinusitis\nHave you ever had Pulmonary Tuberculosis ? If so, when\nno.\nWhere did you cure?\nIs the condition now arrested?\nHave you ever had a suspected\nPulmonary Tuberculosis ? no. If so, when\nOthers-specify\n5. General physique-cross out those which do not apply.\nFrail\nGood\nRobust\nThin\n-Slender\nObese\nOVER"
}