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FORM 1193
REV. FEB. 1941
AMERICAN RED CROSS NURSING SERVICE
see no reason in
PHYSICAL EXAMINATION
here adv. conditions #
see revised
(All questions must be answered by definite statements)
sand please
1. Name of applicant. Henrietta Fitch
1/3/42
Address 75 Score St,
City moutclair.
2. Age 32
Height (Feet and inches) Weight 112 (pounds)
State new Jersey
-16
3. Family history
4. Past history: General health, operation, injury, any illnesses (Indicate dates) Good
V Chalecystectomy- - 1939- appendectomy - 1930 Jousillestomy 1931.
5. General physique will nourished well developed
(Rt. eye 20/201
(Rt. 20/
6. Distant Vision: Without glasses
Lt. eye 20 /20/
With glasses
Lt. 20/
}
SR. LL.
nove
Evidence of disease
none
Note: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
(Rt. ear 10/20 ft.
7. Hearing: (Whispered voice)
Evidence of disease
SRt. none
(Lt. ear 80/20 ft.)
Lt.
none
8. Teeth and gums: (Note abnormalities)
Directions: Indicate as follows-
Right
Applicant's
Left
X
U8
Missing tooth
Teeth:
7
6
43
1
1
2345678
L8
6
$ 4 3 1 2 1
12345878
Bridgework
Crown
"Plate"-write out word to indicate plate.
9. Nose and Throat
no evidence of disease
10. Neck: (Thyroid gland and other abnormalities) normal
11. Skeletal: (Bones, joints, muscles and feet) 10 proxation g fat
12. Thorax: Expiration
32
inches
Inspiration
34
inches
Respiration
18
per minute
Cardio-vascular system normal
Lungs to percussion and auscultation clear throughout
Heart: Size normal
Murmurs none
13
Pulse
70
:
Blood pressure: S 104
D 68
(Over)
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"ocrText": "FORM 1193\nREV. FEB. 1941\nAMERICAN RED CROSS NURSING SERVICE\nsee no reason in\nPHYSICAL EXAMINATION\nhere adv. conditions #\nsee revised\n(All questions must be answered by definite statements)\nsand please\n1. Name of applicant. Henrietta Fitch\n1/3/42\nAddress 75 Score St,\nCity moutclair.\n2. Age 32\nHeight (Feet and inches) Weight 112 (pounds)\nState new Jersey\n-16\n3. Family history\n4. Past history: General health, operation, injury, any illnesses (Indicate dates) Good\nV Chalecystectomy- - 1939- appendectomy - 1930 Jousillestomy 1931.\n5. General physique will nourished well developed\n(Rt. eye 20/201\n(Rt. 20/\n6. Distant Vision: Without glasses\nLt. eye 20 /20/\nWith glasses\nLt. 20/\n}\nSR. LL.\nnove\nEvidence of disease\nnone\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\n(Rt. ear 10/20 ft.\n7. Hearing: (Whispered voice)\nEvidence of disease\nSRt. none\n(Lt. ear 80/20 ft.)\nLt.\nnone\n8. Teeth and gums: (Note abnormalities)\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nX\nU8\nMissing tooth\nTeeth:\n7\n6\n43\n1\n1\n2345678\nL8\n6\n$ 4 3 1 2 1\n12345878\nBridgework\nCrown\n\"Plate\"-write out word to indicate plate.\n9. Nose and Throat\nno evidence of disease\n10. Neck: (Thyroid gland and other abnormalities) normal\n11. Skeletal: (Bones, joints, muscles and feet) 10 proxation g fat\n12. Thorax: Expiration\n32\ninches\nInspiration\n34\ninches\nRespiration\n18\nper minute\nCardio-vascular system normal\nLungs to percussion and auscultation clear throughout\nHeart: Size normal\nMurmurs none\n13\nPulse\n70\n:\nBlood pressure: S 104\nD 68\n(Over)"
}