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FORM 1193
THE AMERICAN RED CROSS NURSING SERVICE
REV. 6.15.25
PHYSICAL EXAMINATION
ar
(Follow instructions at foot of page in answering all questions)
+
5
1. Name of applicant martha Fround
Badge No.
Address
City St Louis State missouri
a
7034 Wise ave
2.
Age 30 you
Height
5 ft 3/4 in
Weight
121 1/2 ths
good
D
3. General physique.
-
4. Tendency to disease, inherited or otherwise
none
-
e
5. in to serious or
Previous history regard illness surgical operation Tousels removed;
1
n
6. Has she had rheumatism ? no
e
7. Has she at present or has she ever had hernia ? no
B
8. Condition of teeth
Good
9. Condition of Bones and Joints no abnormalities Flat Foot none
10. Abdomen and contained organs No pathology
11. Chest and contained organs Nr pathology
Girth: Expiration
3 t
inches. Inspiration 36
inches
Respiration, rate of
20
Heart, pulse rate 80
Right eye (Snellen) 20-20- Corrected to 20-20
lens used
12. Vision:
Left eye (Snellen) 20-20- Corrected to 20-20
lens used
NOTE.-Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20,20-50,20-100, etc.
If glasses
are worn state correction.
13. Hearing: Right
20-20
Left 20-20
Hearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.
14. Urine examination :
Color yellow
Reaction
neutral
Specific gravity
1014
Albumen
neg
Casts
meg
Leucocytes
neg
Sugar
15. Do you recommend applicant for active hospital service? yes
meg
Ptudent Health pervice M. D.
Date July 6,1933
Address
At houis University
All questions MUST be answered; otherwise certificate will not be accepted at Headquarters.
To be forwarded to the Local Committee on Red Cross Nursing Service.
1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.
2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.
8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.
9. Flat foot-state whether or not any inconvenience exists.
11. Chest measurements should be in total inches.
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- Source index
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Document data
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"ocrText": "a\nFORM 1193\nTHE AMERICAN RED CROSS NURSING SERVICE\nREV. 6.15.25\nPHYSICAL EXAMINATION\nar\n(Follow instructions at foot of page in answering all questions)\n+\n5\n1. Name of applicant martha Fround\nBadge No.\nAddress\nCity St Louis State missouri\na\n7034 Wise ave\n2.\nAge 30 you\nHeight\n5 ft 3/4 in\nWeight\n121 1/2 ths\ngood\nD\n3. General physique.\n-\n4. Tendency to disease, inherited or otherwise\nnone\n-\ne\n5. in to serious or\nPrevious history regard illness surgical operation Tousels removed;\n1\nn\n6. Has she had rheumatism ? no\ne\n7. Has she at present or has she ever had hernia ? no\nB\n8. Condition of teeth\nGood\n9. Condition of Bones and Joints no abnormalities Flat Foot none\n10. Abdomen and contained organs No pathology\n11. Chest and contained organs Nr pathology\nGirth: Expiration\n3 t\ninches. Inspiration 36\ninches\nRespiration, rate of\n20\nHeart, pulse rate 80\nRight eye (Snellen) 20-20- Corrected to 20-20\nlens used\n12. Vision:\nLeft eye (Snellen) 20-20- Corrected to 20-20\nlens used\nNOTE.-Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20,20-50,20-100, etc.\nIf glasses\nare worn state correction.\n13. Hearing: Right\n20-20\nLeft 20-20\nHearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.\n14. Urine examination :\nColor yellow\nReaction\nneutral\nSpecific gravity\n1014\nAlbumen\nneg\nCasts\nmeg\nLeucocytes\nneg\nSugar\n15. Do you recommend applicant for active hospital service? yes\nmeg\nPtudent Health pervice M. D.\nDate July 6,1933\nAddress\nAt houis University\nAll questions MUST be answered; otherwise certificate will not be accepted at Headquarters.\nTo be forwarded to the Local Committee on Red Cross Nursing Service.\n1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.\n2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.\n8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.\n9. Flat foot-state whether or not any inconvenience exists.\n11. Chest measurements should be in total inches."
}