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Form 1193
Rev. March 1942
AMERICAN RED CROSS
Report of Physical Condition of Nurse
(Please answer all questions completely and accurately)
Applicant can answer all questions herself, except number 6, with which she will need assistance.
1. Name
Conrad
Faratty
Watteris
(Last)
(First)
(Middle)
2. Age 4.3
Height 5ft 4 inches
Weight 134
pounds
3. Family history: Indicate, in the space opposite the disease, which member of your family, if any, has had
the following, and when. Cross out those which no one has had.
Tuberculosis
Hasband 1922- arrested how Were you a contact?
yes
Cancer ho
Diabetes ho
Heart disease
ho
Epilepsy
Mental illness-
4. Past medical history: General health
Excellent
Operations-specify nature of, and year Touselendany 1922; 1941
Injuries-specify have
Illnesses-cross out the ones which you have not had. Indicate the dates when you had the others:
Allorgic-conditions
Arthritis
Cancer
Communicable diseases (specify) meadles, mumpe, whoaping Caugh
Diabetes
Hay fever
Heart disease
Hypertension
Migraine
Nervous or mental
Rheumatic fever
Sinusitis
I
Have you ever had Pulmonary Tuberculosis If-so, when
Where did you cure' ?
Is the condition now arrested?
Have you ever had a suspected
8
Pulmonary Tuberculosis?
If so, when
Others-specify
5. General physique-cross out those which do not apply.
Frail-
Good
Robust
Thin
Slender-
Obese
OVER
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Document data
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- Core
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"ocrText": "Form 1193\nRev. March 1942\nAMERICAN RED CROSS\nReport of Physical Condition of Nurse\n(Please answer all questions completely and accurately)\nApplicant can answer all questions herself, except number 6, with which she will need assistance.\n1. Name\nConrad\nFaratty\nWatteris\n(Last)\n(First)\n(Middle)\n2. Age 4.3\nHeight 5ft 4 inches\nWeight 134\npounds\n3. Family history: Indicate, in the space opposite the disease, which member of your family, if any, has had\nthe following, and when. Cross out those which no one has had.\nTuberculosis\nHasband 1922- arrested how Were you a contact?\nyes\nCancer ho\nDiabetes ho\nHeart disease\nho\nEpilepsy\nMental illness-\n4. Past medical history: General health\nExcellent\nOperations-specify nature of, and year Touselendany 1922; 1941\nInjuries-specify have\nIllnesses-cross out the ones which you have not had. Indicate the dates when you had the others:\nAllorgic-conditions\nArthritis\nCancer\nCommunicable diseases (specify) meadles, mumpe, whoaping Caugh\nDiabetes\nHay fever\nHeart disease\nHypertension\nMigraine\nNervous or mental\nRheumatic fever\nSinusitis\nI\nHave you ever had Pulmonary Tuberculosis If-so, when\nWhere did you cure' ?\nIs the condition now arrested?\nHave you ever had a suspected\n8\nPulmonary Tuberculosis?\nIf so, when\nOthers-specify\n5. General physique-cross out those which do not apply.\nFrail-\nGood\nRobust\nThin\nSlender-\nObese\nOVER"
}