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D M R Form No. 29
SCOOS
NURSIN SERVICE
THE
3
WASHINGTON
PHYSICAL EXAMINATION
I. Name of applicant Dan 7. Butter
Address. 188 farm St.
2. Age 49-
Height 5ft
City Hariford Weight 149 State One
3. General physique
4. Tendency to disease, inherited or otherwise
none
5. Previous history in regard to serious illness or surgical operation Typhoid fiver at 24 yrs. of
agr. Tousilectormy in 1914.
6. Has she had rheumatism? mild, transitory arthritis no guff kun, 1915
7. Has she at present or has she ever had hernia?
8. Condition of teeth
good
9. Condition of feet
normal
10. Abdomen and contained organs
normal
II. Chest and contained organs
normal
Expiration
37 -
inches.
Inspiration
39.
inches.
12. Vision: O. D myopeia, corrected to 20/20 Hearing: A. D.
20/20
O. S. 11/20
" " 20/20.
A.S.
20/20
NOTE: In case of refractive error state degree of correction by glasses.
13. Urine examination:
Color amber
Reaction
acid
Specific gravity
1015
Albumen
no.
Casts.
no
Leucocytes
no
no
Sugar
14. Do you recommend applicant for:
(a) General hospital service.
yes
(b) Tropical service
no
He
15. Fill in location of base hospital, unit or detachment with which service is desired:
Army base hospital at
Naval base hospital at
Field service with Red Cross unit in
Emergency detachment at Franch
Navy detachment at
Hospital unit at
Surgical section at
M. D.
Date
Address
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--20M
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"ocrText": "D M R Form No. 29\nSCOOS\nNURSIN SERVICE\nTHE\n3\nWASHINGTON\nPHYSICAL EXAMINATION\nI. Name of applicant Dan 7. Butter\nAddress. 188 farm St.\n2. Age 49-\nHeight 5ft\nCity Hariford Weight 149 State One\n3. General physique\n4. Tendency to disease, inherited or otherwise\nnone\n5. Previous history in regard to serious illness or surgical operation Typhoid fiver at 24 yrs. of\nagr. Tousilectormy in 1914.\n6. Has she had rheumatism? mild, transitory arthritis no guff kun, 1915\n7. Has she at present or has she ever had hernia?\n8. Condition of teeth\ngood\n9. Condition of feet\nnormal\n10. Abdomen and contained organs\nnormal\nII. Chest and contained organs\nnormal\nExpiration\n37 -\ninches.\nInspiration\n39.\ninches.\n12. Vision: O. D myopeia, corrected to 20/20 Hearing: A. D.\n20/20\nO. S. 11/20\n\" \" 20/20.\nA.S.\n20/20\nNOTE: In case of refractive error state degree of correction by glasses.\n13. Urine examination:\nColor amber\nReaction\nacid\nSpecific gravity\n1015\nAlbumen\nno.\nCasts.\nno\nLeucocytes\nno\nno\nSugar\n14. Do you recommend applicant for:\n(a) General hospital service.\nyes\n(b) Tropical service\nno\nHe\n15. Fill in location of base hospital, unit or detachment with which service is desired:\nArmy base hospital at\nNaval base hospital at\nField service with Red Cross unit in\nEmergency detachment at Franch\nNavy detachment at\nHospital unit at\nSurgical section at\nM. D.\nDate\nAddress\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--20M"
}