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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
0
Do you have any impairment of hearing? Yes
No ho
T
C
If so, specify degree-Slight
Moderate
Marked
+
8. Teeth: Gums
good
Cavities
have
(Condition)
(How many)
Y
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
//
Upper 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Upper
a
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
2-21-41
Louston Wu . Caurael.
(Date)
(Signature)
I
8
N
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": "O\n6.\nDistant 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.\n(Right 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\n0\nDo you have any impairment of hearing? Yes\nNo ho\nT\nC\nIf so, specify degree-Slight\nModerate\nMarked\n+\n8. Teeth: Gums\ngood\nCavities\nhave\n(Condition)\n(How many)\nY\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\n//\nUpper 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Upper\na\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\n.Typhoid 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 1\nDate and result of last Dick test\nNegative\nPositive\n10. What is your present physical condition?\nScallent\nIf any disabilities, please specify\n2-21-41\nLouston Wu . Caurael.\n(Date)\n(Signature)\nI\n8\nN\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment."
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