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FORM 1193
AMERICAN RED CROSS NURSING SERVICE
REV. 10-26-38
I
PHYSICAL EXAMINATION
81
M
(Follow instructions at end of form in answering all questions)
a
many marget Dadds
a
1. Name of applicant
, Address 419West 114 Street City new your
2. Age
25 yrs
5' 6"
State newyork
Height
Weight 135lbs
M
3.
Family history mother-lows, father-bow, brothers , sister - lxw
4. Past history: General health, operation, injury, any illnesses
general health - good
no operations sinjuaical
5.
General physique 9 ood
+
6. Eyes: Pupils; Right eye; Distant vision 20/20 Corrected to
Lens used
6K-
Left eye; Distant vision 20/20 /Corrected to
Lens used
NOTE:-Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
If glasses are worn state correction.
7. Ears: :
normal
renimax3
8. Teeth (note good
and gums abnormalities)
NOTE:-Check chart on other side of blank.
9. Throat hormal
10, Neck: (Thyroid gland and other abnormalities)
normal
11. Skeletal: (Bones, joints, muscles and feet)
normal
12. Thorax: 31/4 inches
Expiration
XTOW
Inspiration
33% inches
Respiration
16
per minute
Lungs to percussion and auscultation
normal
Cardio-vascular system
11
Heart: Size normal
W
abnses
W
Murmurs none
2
Pulse 72
Blood pressure: S 124
D so
(Over)
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"ocrText": "FORM 1193\nAMERICAN RED CROSS NURSING SERVICE\nREV. 10-26-38\nI\nPHYSICAL EXAMINATION\n81\nM\n(Follow instructions at end of form in answering all questions)\na\nmany marget Dadds\na\n1. Name of applicant\n, Address 419West 114 Street City new your\n2. Age\n25 yrs\n5' 6\"\nState newyork\nHeight\nWeight 135lbs\nM\n3.\nFamily history mother-lows, father-bow, brothers , sister - lxw\n4. Past history: General health, operation, injury, any illnesses\ngeneral health - good\nno operations sinjuaical\n5.\nGeneral physique 9 ood\n+\n6. Eyes: Pupils; Right eye; Distant vision 20/20 Corrected to\nLens used\n6K-\nLeft eye; Distant vision 20/20 /Corrected to\nLens used\nNOTE:-Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\nIf glasses are worn state correction.\n7. Ears: :\nnormal\nrenimax3\n8. Teeth (note good\nand gums abnormalities)\nNOTE:-Check chart on other side of blank.\n9. Throat hormal\n10, Neck: (Thyroid gland and other abnormalities)\nnormal\n11. Skeletal: (Bones, joints, muscles and feet)\nnormal\n12. Thorax: 31/4 inches\nExpiration\nXTOW\nInspiration\n33% inches\nRespiration\n16\nper minute\nLungs to percussion and auscultation\nnormal\nCardio-vascular system\n11\nHeart: Size normal\nW\nabnses\nW\nMurmurs none\n2\nPulse 72\nBlood pressure: S 124\nD so\n(Over)"
}