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THE AMERICAN RED CROSS NURSING SERVICE
FORM 1193
REV. 10-22-36
M
11
10
Ressa'
PHYSICAL EXAMINATION
in,
a
T
(Follow instructions at end of form in answering all questions)
1. Name of applicant Maxian Bilkz
an
Address Forest Hall
City Bloomington
State Indiana
2. Age 22
Height
5 ft. 842 in
Weight
175
good
L
3. General physique
-
4. Tendency to disease,
inherited or otherwise name
' a
5. Previous history in regard to operation, injury or illness Nump
6. Vision: Right eye; Distant vision 20/20 Corrected to
-
Lens used
Left eye; Distant vision 20/24 Corrected to checkmark_ntt
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.
good
7. Hearing: Right ear; Watch
for
(40"
Whispered voice
/15'
Left ear; Watch
good
/40"
Whispered voice
/15
8. Teeth and gums: (note abnormalities nm
NOTE-Check chart on other side of blank.
9. Neck: (Thyroid glands and other abnormalities)
mind
10. Spine and extremities; (bones, joints, muscles and feet)
none
11. Thorax: Respiratory system, bronchi, lungs, pleura, etc none
Expiration
43
inches
Inspiration
41 inches
20
Respiration
per minute
Cardio-vascular system
normal
Heart: (note all signs of cardiac involvement) nml
Pulse 76 Blood pressure: S 122
D 82
(Over)
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"ocrText": "B\n-\n-\n+\nTHE AMERICAN RED CROSS NURSING SERVICE\nFORM 1193\nREV. 10-22-36\nM\n11\n10\nRessa'\nPHYSICAL EXAMINATION\nin,\na\nT\n(Follow instructions at end of form in answering all questions)\n1. Name of applicant Maxian Bilkz\nan\nAddress Forest Hall\nCity Bloomington\nState Indiana\n2. Age 22\nHeight\n5 ft. 842 in\nWeight\n175\ngood\nL\n3. General physique\n-\n4. Tendency to disease,\ninherited or otherwise name\n' a\n5. Previous history in regard to operation, injury or illness Nump\n6. Vision: Right eye; Distant vision 20/20 Corrected to\n-\nLens used\nLeft eye; Distant vision 20/24 Corrected to checkmark_ntt\nLens used\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.\ngood\n7. Hearing: Right ear; Watch\nfor\n(40\"\nWhispered voice\n/15'\nLeft ear; Watch\ngood\n/40\"\nWhispered voice\n/15\n8. Teeth and gums: (note abnormalities nm\nNOTE-Check chart on other side of blank.\n9. Neck: (Thyroid glands and other abnormalities)\nmind\n10. Spine and extremities; (bones, joints, muscles and feet)\nnone\n11. Thorax: Respiratory system, bronchi, lungs, pleura, etc none\nExpiration\n43\ninches\nInspiration\n41 inches\n20\nRespiration\nper minute\nCardio-vascular system\nnormal\nHeart: (note all signs of cardiac involvement) nml\nPulse 76 Blood pressure: S 122\nD 82\n(Over)"
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