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I
e
B. If a wife, is she now pregnant?
to arli 7
XI. Has the applicant ever had-
oviteogib orls
XI.
A. Rheumatism, acute or chronic?
IV
A no
TV
B. Malaria?
B. no
I
C. Other fever?
C. ho
a
D. Any disease or injury not included in pre-
D no
etast yd
ceding questions?
-
XII. Has the applicant noticed any recent marked
XII.
no TO atas) vd el s
gain or loss in flesh ?
31 10 a
XIII. Would you recommend the applicant to a
XIII. you the orrought
S
reputable Life Insurance Company as a pru-
dent risk?
XIV. Do you professionally consider the applicant
XIV. yes
a suitable person, physically, for appointment
to overseas work?
ai 10 mood 19V9 exH
odt lo
XV. Would a tropical climate be likely to induce
XV. No
disease or cause disablement ?
IIII
XVI. Are there any facts known to you, or dis-
XVI. M
covered by you, not brought out in the above
questions, affecting or likely to affect the
benimaxe ad bítioda valt
health of the applicant If so, please state
them.
XVII. Is there, in general, a soundness of constitu-
XVII. Yes
tion and a vigor of health which give reason-
able probability that the applicant can endure
XI
the physical and mental strain of overseas
: to sid to 10
work?
XVIII. When was the applicant last successfully
XVIII. 7.2.1919
vaccinated?
XIX. Has the applicant had typhoid fever or the
anti-typhoid inoculation?
XIX. Typhone 898- Quoc (2) 1918
NOTE
Before final credentials are issued to any person enrolled for foreign service for the American Red Cross, a
certificate or certificates must be furnished of vaccination and inoculation against smallpox, typhoid and para-
typhoid fever, or in lieu thereof, a certificate by a physician, approved by the Medical Adviser of the Division
receiving the application, that such person has recently suffered from the disease for the prevention of which there
has been no immunization by vaccination or preventive inoculation.
city
Signature of Medical Examiner.
MARK RDSON
M. D.
IDSTON, MASS
Address
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