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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
chart read at 20 feet.
Right eye 20/
Right eye 20/
Without glasses
With glasses, if worn
Left eye 20/
Left eye 20/
7. Ears and Hearing: Do you have a perforated ear drum?
ho
Do you have any impairment of hearing? Yes
No ho
If so, specify degree-Slight
Moderate
Marked
8. Teeth: Gums
good
Cavities
have
(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
a
Upper 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Upper
+
Lower 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Lower
9. Date of immunization against Smallpox
1940
Typhoid Idad the disease in 1914
Have you been immunized against Tetanus:
yes
When
1922
Diphtheria?
yes
"
19224 yearly
Scarlet fever? ho
"
Date and result of last Schick test
1940
Negative
Positive
1
Date and result of last Dick test
Negative
Positive
10. What is your present physical condition?
Scallent
If any disabilities, please specify
5-21-42
Louaton W. Cuural
(Date)
(Signature)
8
This form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for
enrollment.
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- Type
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Document data
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"ocrText": "Lane\n1\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\nchart read at 20 feet.\nRight eye 20/\nRight eye 20/\nWithout glasses\nWith glasses, if worn\nLeft eye 20/\nLeft eye 20/\n7. Ears and Hearing: Do you have a perforated ear drum?\nho\nDo you have any impairment of hearing? Yes\nNo ho\nIf so, specify degree-Slight\nModerate\nMarked\n8. Teeth: Gums\ngood\nCavities\nhave\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\n//\nYour right\nYour left\na\nUpper 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Upper\n+\nLower 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Lower\n9. Date of immunization against Smallpox\n1940\nTyphoid Idad the disease in 1914\nHave you been immunized against Tetanus:\nyes\nWhen\n1922\nDiphtheria?\nyes\n\"\n19224 yearly\nScarlet fever? ho\n\"\nDate and result of last Schick test\n1940\nNegative\nPositive\n1\nDate and result of last Dick test\nNegative\nPositive\n10. What is your present physical condition?\nScallent\nIf any disabilities, please specify\n5-21-42\nLouaton W. Cuural\n(Date)\n(Signature)\n8\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment."
}