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Mr
6. Distant vision : This must be obtained by testing with Snellen Vision Chart at 20-foot distance and recorded
as a fraction, the numerator of which is the distance and the denominator the line on the
F.
un
chart read at 20 feet.
Right eye 20/
(Right eye 20/
I
Without glasses
With glasses, if worn
Left eye 20/
Left eye 20/
E.J.)
A
17. Ears and Hearing: Do you have a perforated ear drum ?
No
a
Do you have any impairment of hearing?
Kess
No
If so, specify degree-Slight
Moderate
Marked
8. Teeth: Gums
Very good
Cavities none: some fillings.
(Condition)
(How many)
Indicate on the chart below, the following conditions:
Missing teeth by X
Bridge work by
Plate-write out the word "plate" and indicate whether upper or lower
Your right
Your left
0
Upper &8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Upper
+
(only wisdom
Lower 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Lower,
teeth missing)
X
X
9. Date of immunization against Smallpox about 1927
Typhoid never
Have you been immunized against Tetanus? no
When
Diphtheria?
no
"
Scarlet fever ? no
"
Date and result of last Schick test never
Negative
Positive
Date and result of last Dick test
never
Negative
Positive
10. What is your present physical condition ?
Very good.
I
If any disabilities, please specify
---
Dola D. Coe
I
August 17, 1942
(Date)
(Signature)
10,
U
This form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for
enrollment.
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"ocrText": "Mr\n6. Distant vision : This must be obtained by testing with Snellen Vision Chart at 20-foot distance and recorded\nas a fraction, the numerator of which is the distance and the denominator the line on the\nF.\nun\nchart read at 20 feet.\nRight eye 20/\n(Right eye 20/\nI\nWithout glasses\nWith glasses, if worn\nLeft eye 20/\nLeft eye 20/\nE.J.)\nA\n17. Ears and Hearing: Do you have a perforated ear drum ?\nNo\na\nDo you have any impairment of hearing?\nKess\nNo\nIf so, specify degree-Slight\nModerate\nMarked\n8. Teeth: Gums\nVery good\nCavities none: some fillings.\n(Condition)\n(How many)\nIndicate on the chart below, the following conditions:\nMissing teeth by X\nBridge work by\nPlate-write out the word \"plate\" and indicate whether upper or lower\nYour right\nYour left\n0\nUpper &8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Upper\n+\n(only wisdom\nLower 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Lower,\nteeth missing)\nX\nX\n9. Date of immunization against Smallpox about 1927\nTyphoid never\nHave you been immunized against Tetanus? no\nWhen\nDiphtheria?\nno\n\"\nScarlet fever ? no\n\"\nDate and result of last Schick test never\nNegative\nPositive\nDate and result of last Dick test\nnever\nNegative\nPositive\n10. What is your present physical condition ?\nVery good.\nI\nIf any disabilities, please specify\n---\nDola D. Coe\nI\nAugust 17, 1942\n(Date)\n(Signature)\n10,\nU\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment."
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