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Form 1193-Rev. 2-9-22
Superseding D. M.R.29
5
THE AMERICAN RED CROSS NURSING SERVICE
as,
PHYSICAL EXAMINATION
1. Name of applicant Verda Violet Cummings
L
Badge No.
Address 613 Kearney it
City Portland
State OVE
er
a
2. Age 24
Height 5 feet 2 in Weight 118 las with clothes.
a
3. General Physique good
a
4. Tendency to disease, Unherited or otherwise
negatin
Previous history regard appendicting may
L
5. in to serious illness or surgical operation
appendectomy- - may 1923- notrouble since.
- -
0
6. Has she had rheumatism?
no
-
7. Has she at present or has she ever had hernia? no
e
8. Condition of teeth good. fource - one tooth missing.
+
9. Condition of feet good
10. Abdomen and contained organs good
11. Chest and contained organs
cllar.
Girth: Expiration 30.
inches. Inspiration 3 3
inches.
Respiration, rate of 18
Heart, pulse rate 78
Right eye (Snellen) 115- 20 Corrected to
-
lens used -
12. Vision:
-
-
Left eye (Snellen) 20-1 Corrected to
lens used
13. Hearing: A. D. 12/20
A. S. 100
14. Urine examination :
B
Color clear amber
Reaction
acid
Specific gravity 1020
Albumen
neg.
Casts
neq
Leucocytes
neg
Dr. w OsBorne
Sugar
neq
15. Do you recommend applicant for Active Hospital service?
yes
Harold C. Bean
M.D.
Date may All(questions 23-1924 MUST be answered; ;otherwise certificate will Address not be accepted Selling at Headquarters. Bldg Poisland or
To be- forwarded to the Local Committee on Red Cróss Nursing Service.
1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.
2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.
8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.
9. Flat foot-state whether or not any inconvenience exists.
11. Chest measurements should be in total inches.
12. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20/20,20/50,20/100.
If glasses
are worn state correction. Hearing should record whispered voice at 15 feet, 15/15, 10/15, etc.
CA
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Document data
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"ocrText": "Form 1193-Rev. 2-9-22\nSuperseding D. M.R.29\n5\nTHE AMERICAN RED CROSS NURSING SERVICE\nas,\nPHYSICAL EXAMINATION\n1. Name of applicant Verda Violet Cummings\nL\nBadge No.\nAddress 613 Kearney it\nCity Portland\nState OVE\ner\na\n2. Age 24\nHeight 5 feet 2 in Weight 118 las with clothes.\na\n3. General Physique good\na\n4. Tendency to disease, Unherited or otherwise\nnegatin\nPrevious history regard appendicting may\nL\n5. in to serious illness or surgical operation\nappendectomy- - may 1923- notrouble since.\n- -\n0\n6. Has she had rheumatism?\nno\n-\n7. Has she at present or has she ever had hernia? no\ne\n8. Condition of teeth good. fource - one tooth missing.\n+\n9. Condition of feet good\n10. Abdomen and contained organs good\n11. Chest and contained organs\ncllar.\nGirth: Expiration 30.\ninches. Inspiration 3 3\ninches.\nRespiration, rate of 18\nHeart, pulse rate 78\nRight eye (Snellen) 115- 20 Corrected to\n-\nlens used -\n12. Vision:\n-\n-\nLeft eye (Snellen) 20-1 Corrected to\nlens used\n13. Hearing: A. D. 12/20\nA. S. 100\n14. Urine examination :\nB\nColor clear amber\nReaction\nacid\nSpecific gravity 1020\nAlbumen\nneg.\nCasts\nneq\nLeucocytes\nneg\nDr. w OsBorne\nSugar\nneq\n15. Do you recommend applicant for Active Hospital service?\nyes\nHarold C. Bean\nM.D.\nDate may All(questions 23-1924 MUST be answered; ;otherwise certificate will Address not be accepted Selling at Headquarters. Bldg Poisland or\nTo be- forwarded to the Local Committee on Red Cróss Nursing Service.\n1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.\n2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.\n8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.\n9. Flat foot-state whether or not any inconvenience exists.\n11. Chest measurements should be in total inches.\n12. Actual vision should be stated, determined on proper letters for 20 foot distance, as 20/20,20/50,20/100.\nIf glasses\nare worn state correction. Hearing should record whispered voice at 15 feet, 15/15, 10/15, etc.\nCA"
}