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FORM 1193
REV. FEB. 1941
AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
All questions must be answered by definite statements)
1. Name of applicant
Thomas Elizabeth
Weight
Address 36. 28 Gigg St City Houston
State zeans
2. Age
40
Height 5-7
Weight 200 the
(feet and inches)
(pounds)
3. Family history
4.
Past history: General health, operation, injury, any illnesses (Indicate dates) Lap - 1932
appendectomy, 1913 - Hennia aepain 1925
5. General physique
,
6. Distant Vision: Without glasses
fire eye 20/10 With glasses
(Rt. eye 20/7P
{
(Rt. 20/
(Lt. 20/
}
(Rt.
Evidence of disease
il.
Note: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
SR. ear 15/20 ft.)
7. Hearing: (Whispered voice)
Evidence of disease
fRt
(Lt. ear 15/20 ft.
Lt.
8.
Teeth and gums: (Note abnormalities) tain many immering
Directions: Indicate as follows-
Right
Applicant's
Left
Teeth: 654321 654321
UX
Missing tooth
1
123456
Bridgework
Crown
"Plate"-write out word to indicate plate.
9. Nose and Throat
Jesich have been removed
10. Neck: (Thyroid gland and other abnormalities) no absornatitie
11. Skeletal: (Bones, joints, muscles and feet)
no abnormalities
12. Thorax: Expiration
40
inches
Inspiration
47
inches
Respiration
12
per minute
Lungs to percussion and auscultation
normal
Cardio-vascular system
normal
Heart: Size
normal
Murmurs
none
Pulse 78
Blood pressure:
$ 116
D 82
(Over)
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"ocrText": "FORM 1193\nREV. FEB. 1941\nAMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\nAll questions must be answered by definite statements)\n1. Name of applicant\nThomas Elizabeth\nWeight\nAddress 36. 28 Gigg St City Houston\nState zeans\n2. Age\n40\nHeight 5-7\nWeight 200 the\n(feet and inches)\n(pounds)\n3. Family history\n4.\nPast history: General health, operation, injury, any illnesses (Indicate dates) Lap - 1932\nappendectomy, 1913 - Hennia aepain 1925\n5. General physique\n,\n6. Distant Vision: Without glasses\nfire eye 20/10 With glasses\n(Rt. eye 20/7P\n{\n(Rt. 20/\n(Lt. 20/\n}\n(Rt.\nEvidence of disease\nil.\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\nSR. ear 15/20 ft.)\n7. Hearing: (Whispered voice)\nEvidence of disease\nfRt\n(Lt. ear 15/20 ft.\nLt.\n8.\nTeeth and gums: (Note abnormalities) tain many immering\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nTeeth: 654321 654321\nUX\nMissing tooth\n1\n123456\nBridgework\nCrown\n\"Plate\"-write out word to indicate plate.\n9. Nose and Throat\nJesich have been removed\n10. Neck: (Thyroid gland and other abnormalities) no absornatitie\n11. Skeletal: (Bones, joints, muscles and feet)\nno abnormalities\n12. Thorax: Expiration\n40\ninches\nInspiration\n47\ninches\nRespiration\n12\nper minute\nLungs to percussion and auscultation\nnormal\nCardio-vascular system\nnormal\nHeart: Size\nnormal\nMurmurs\nnone\nPulse 78\nBlood pressure:\n$ 116\nD 82\n(Over)"
}