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Form 1193
Rev.6-15-15
THE AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(Follow instructions at foot of page in answering all questions)
0
1.
Name Address of applicant 303 Beuchat City Louisirlle
Badge No.
State Ohio
2. Age 23
Height
good
5' 4 14 Weight
120 34
3. General physique
4. Tendency disease, otherwise
to inherited or
no
5. Previous history in regard to serious illness or surgical operation T+A 1971
no
D
6. Has she had rheumatism ?
7. Has she at present or has she ever had hernia
no
good
A
T
8. Condition of teeth
a
9. Condition of Bones and Joints Normal ,
Flat Foot
1 in
2nd sleg
(Right eye (snellen) 20-20 lens used none
12. Vision:(
cun
(Left eye (snellen) 20-20 lens used. none
inches
(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.)
.M.D.
If glasses
Josephine Dora Bunchat
akron, Ohio
14. Urine examination :
Color
Aust
Reaction
ac
Specific gravity
Albumen
o
0
C
Casts
Leucocytes
Sugar
0
15. Do you recommend applicant for hospital service? yea
active
Date 5/24/32
ganes
M.D.
Address 11025 turbed are
5
All questions MUST be answered; otherwise certificate will not be accepted at Headquarters.
(5
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.
2
D.
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Document data
- ID
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- Core
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"ocrText": "B\nForm 1193\nRev.6-15-15\nTHE AMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(Follow instructions at foot of page in answering all questions)\n0\n1.\nName Address of applicant 303 Beuchat City Louisirlle\nBadge No.\nState Ohio\n2. Age 23\nHeight\ngood\n5' 4 14 Weight\n120 34\n3. General physique\n4. Tendency disease, otherwise\nto inherited or\nno\n5. Previous history in regard to serious illness or surgical operation T+A 1971\nno\nD\n6. Has she had rheumatism ?\n7. Has she at present or has she ever had hernia\nno\ngood\nA\nT\n8. Condition of teeth\na\n9. Condition of Bones and Joints Normal ,\nFlat Foot\n1 in\n2nd sleg\n(Right eye (snellen) 20-20 lens used none\n12. Vision:(\ncun\n(Left eye (snellen) 20-20 lens used. none\ninches\n(Actual vision should be stated, determined on proper letters for 20 foot\ndistance, as 20-20, 20-50, 20-100, etc. If glasses are worn state\ncorrection.)\n.M.D.\nIf glasses\nJosephine Dora Bunchat\nakron, Ohio\n14. Urine examination :\nColor\nAust\nReaction\nac\nSpecific gravity\nAlbumen\no\n0\nC\nCasts\nLeucocytes\nSugar\n0\n15. Do you recommend applicant for hospital service? yea\nactive\nDate 5/24/32\nganes\nM.D.\nAddress 11025 turbed are\n5\nAll questions MUST be answered; otherwise certificate will not be accepted at Headquarters.\n(5\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.\n2\nD."
}