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FORM 1193
REV. 10-26-38
AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(Follow instructions at end of form in answering all questions)
1. Name of applicant Sillian Evans
Address 40Westminster Que.
City Brtington
State Mass
2. Age 22
Height 5 ft 8 1/2 in Weight 150
3. Family history negative
4. Past history: General health, operation, injury, any illnesses negative
megales, mmps, wh cough, searlet fever, chicken pox.
5. General physique Ok
6. Eyes: Pupils; Right eye; Distant vision 20/20 Corrected to
Lens used
us
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.I edenall
8. Teeth and gums: (note abnormalities) normal.
NOTE:-Check charton other side of blank.
9. Throat normal
10. Neck: (Thyroid gland and other abnormalities not enlorged
11. Skeletal: (Bones, joints, muscles and feet) normal
12. Thorax: Expiration 32
inches
Inspiration 34
inches
Respiration 18
8
per minute
Lungs to percussion and auscultation clear.
LIA
5
Cardio-vascular system normal
8
Heart: Size Point impulse 7emcD ileft misternal line.
Murmurs none.
8
Pulse 84
Blood pressure: S 120
D 80
(Over)
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"ocrText": "\"T\nL\ns\nS\"\nFORM 1193\nREV. 10-26-38\nAMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(Follow instructions at end of form in answering all questions)\n1. Name of applicant Sillian Evans\nAddress 40Westminster Que.\nCity Brtington\nState Mass\n2. Age 22\nHeight 5 ft 8 1/2 in Weight 150\n3. Family history negative\n4. Past history: General health, operation, injury, any illnesses negative\nmegales, mmps, wh cough, searlet fever, chicken pox.\n5. General physique Ok\n6. Eyes: Pupils; Right eye; Distant vision 20/20 Corrected to\nLens used\nus\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.\nEars: normal.I edenall\n8. Teeth and gums: (note abnormalities) normal.\nNOTE:-Check charton other side of blank.\n9. Throat normal\n10. Neck: (Thyroid gland and other abnormalities not enlorged\n11. Skeletal: (Bones, joints, muscles and feet) normal\n12. Thorax: Expiration 32\ninches\nInspiration 34\ninches\nRespiration 18\n8\nper minute\nLungs to percussion and auscultation clear.\nLIA\n5\nCardio-vascular system normal\n8\nHeart: Size Point impulse 7emcD ileft misternal line.\nMurmurs none.\n8\nPulse 84\nBlood pressure: S 120\nD 80\n(Over)"
}