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FORM 1193
1941
AMERICAN RED CROSS NURSING SERVICE
JAN
in
PHYSICAL EXAMINATION
(All questions must be answered by definite statements)
PACIFIC BRANCH
RED CROSS
Verda V. Cummings -
L
1. Name of applicant
City Portland
e
Address 930-MW- 20th
State are
a
2. Age
42
Height 5-2
Weight 113 -
a
(feet and inches)
(pounds)
has Essential
a
3. Family history
4. Past history: General health, operation, injury, any illnesses (Indicate dates) Pneumonia 1 1937
L
appenducting - 1923- - Small prx - 1907
5. General physique
good
0
-
-
(Rt. eye 20/201
(Re. 20/
(Rt. none
6. Distant Vision: Without glasses
LL. eye 20/20/
With glasses
(Lt. 20/
}
e
Evidence of disease
LLE name
+
Note: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
(Rt.
(Rt.
home
7. Hearing: (Whispered voice)
20
Evidence of disease
(Lt. ear /20 ft.)
the
(Lt.
none
8. Teeth and gums: (Note abnormalities)
namel
Directions: Indicate as follows-
Right
Applicant's
Left
Missing tooth
Teeth: U8 7 6 5 X 3 2 1 1 2 3 /4 5 6 x
L8 X K 5 4 3 2 1 1 2 3 4 5 6 X
Bridgework
)
Crown
"Plate"-write out word to indicate plate.
qapA ape 10 uneg (o
9. Nose and Throat
normal
10. Neck: (Thyroid gland and other abnormalities)
nmmal
11. Skeletal: (Bones, joints, muscles and feet)
namel
12. Thorax: Expiration
27
inches
Inspiration 301/2 inches
12
Respiration
18
per minute
L
Lungs to percussion and auscultation
normal
0,
Cardio-vascular system
namel
Heart: Size
normal
CA
Murmurs
name
6
Pulse 82
13
Blood pressure: S 114 D 72
(Over)
Page data
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- Core
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"ocrText": "FORM 1193\n1941\nAMERICAN RED CROSS NURSING SERVICE\nJAN\nin\nPHYSICAL EXAMINATION\n(All questions must be answered by definite statements)\nPACIFIC BRANCH\nRED CROSS\nVerda V. Cummings -\nL\n1. Name of applicant\nCity Portland\ne\nAddress 930-MW- 20th\nState are\na\n2. Age\n42\nHeight 5-2\nWeight 113 -\na\n(feet and inches)\n(pounds)\nhas Essential\na\n3. Family history\n4. Past history: General health, operation, injury, any illnesses (Indicate dates) Pneumonia 1 1937\nL\nappenducting - 1923- - Small prx - 1907\n5. General physique\ngood\n0\n-\n-\n(Rt. eye 20/201\n(Re. 20/\n(Rt. none\n6. Distant Vision: Without glasses\nLL. eye 20/20/\nWith glasses\n(Lt. 20/\n}\ne\nEvidence of disease\nLLE name\n+\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\n(Rt.\n(Rt.\nhome\n7. Hearing: (Whispered voice)\n20\nEvidence of disease\n(Lt. ear /20 ft.)\nthe\n(Lt.\nnone\n8. Teeth and gums: (Note abnormalities)\nnamel\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nMissing tooth\nTeeth: U8 7 6 5 X 3 2 1 1 2 3 /4 5 6 x\nL8 X K 5 4 3 2 1 1 2 3 4 5 6 X\nBridgework\n)\nCrown\n\"Plate\"-write out word to indicate plate.\nqapA ape 10 uneg (o\n9. Nose and Throat\nnormal\n10. Neck: (Thyroid gland and other abnormalities)\nnmmal\n11. Skeletal: (Bones, joints, muscles and feet)\nnamel\n12. Thorax: Expiration\n27\ninches\nInspiration 301/2 inches\n12\nRespiration\n18\nper minute\nL\nLungs to percussion and auscultation\nnormal\n0,\nCardio-vascular system\nnamel\nHeart: Size\nnormal\nCA\nMurmurs\nname\n6\nPulse 82\n13\nBlood pressure: S 114 D 72\n(Over)"
}