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D M Form No. 29
8084
NURSING SERVICE
2596
ead
4
PHYSICAL EXAMINATION
alice a. Buckland
I.
Name
of
applicant
Address 394 837 N
B>
City Portland 132 State aug.
D
Height :-4/zzin
11
2. Age
Weight
3. General physique On good health
4.
Tendency to disease, inherited or otherwise Typhont form 19
none.
5. history regard operation Tephind from 1902
Previous in to serious illness or surgical
appendensementation nou
6. Mas she had rheumatism?
my.
7. Has she at present or has she ever had hernia?
name
8. Condition of teeth
bood Condition
9. Condition of feet
no defermaties
IO. Abdomen and contained organs
noture
II. Chest and organs..
contained normals
Expiration
38
inches.
Inspiration
35
inches.
I2. Vision: O. D. 2020 corrected
Hearing: A. D normal
O. S. 2020cm
A.
S. normal
(guly 13. Urine 1914 examination: - Glasses changed. - 0.0 +1.50 + 50 are 115 o )
NOTE: In case of refractive error state degree of correction by glasses.
Color
amban
o.J.t 1.50+ 37 and
Reaction
Specific gravity
1018
Albumen none
Casts
none
Leucocytes none
Sugar
none
14. Do you recommend applicant for:
(a) General hospital service
Home service
OK
MC
(b) Tropical service.
15. Fill in location of base hospital, unit or detachment with which service is desired:
Army base hospital at
Naval base hospital at
Emergency detachment at
Navy detachment at
Hospital unit at
Home service
u
Surgical section at
5
M.
D.
I
Date
Address 802 CarbattBlk
All questions MUST be answered; otherwise certificate will not be accepted at headquarters.
To be forwarded to Chief Nurse of Unit or to Committee Organizing Detachment.
Req. 17-833-May-2CM
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"ocrText": "D M Form No. 29\n8084\nNURSING SERVICE\n2596\nead\n4\nPHYSICAL EXAMINATION\nalice a. Buckland\nI.\nName\nof\napplicant\nAddress 394 837 N\nB>\nCity Portland 132 State aug.\nD\nHeight :-4/zzin\n11\n2. Age\nWeight\n3. General physique On good health\n4.\nTendency to disease, inherited or otherwise Typhont form 19\nnone.\n5. history regard operation Tephind from 1902\nPrevious in to serious illness or surgical\nappendensementation nou\n6. Mas she had rheumatism?\nmy.\n7. Has she at present or has she ever had hernia?\nname\n8. Condition of teeth\nbood Condition\n9. Condition of feet\nno defermaties\nIO. Abdomen and contained organs\nnoture\nII. Chest and organs..\ncontained normals\nExpiration\n38\ninches.\nInspiration\n35\ninches.\nI2. Vision: O. D. 2020 corrected\nHearing: A. D normal\nO. S. 2020cm\nA.\nS. normal\n(guly 13. Urine 1914 examination: - Glasses changed. - 0.0 +1.50 + 50 are 115 o )\nNOTE: In case of refractive error state degree of correction by glasses.\nColor\namban\no.J.t 1.50+ 37 and\nReaction\nSpecific gravity\n1018\nAlbumen none\nCasts\nnone\nLeucocytes none\nSugar\nnone\n14. Do you recommend applicant for:\n(a) General hospital service\nHome service\nOK\nMC\n(b) Tropical service.\n15. Fill in location of base hospital, unit or detachment with which service is desired:\nArmy base hospital at\nNaval base hospital at\nEmergency detachment at\nNavy detachment at\nHospital unit at\nHome service\nu\nSurgical section at\n5\nM.\nD.\nI\nDate\nAddress 802 CarbattBlk\nAll questions MUST be answered; otherwise certificate will not be accepted at headquarters.\nTo be forwarded to Chief Nurse of Unit or to Committee Organizing Detachment.\nReq. 17-833-May-2CM"
}