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THE AMERICAN RED CROSS NURSING SERVICE
FORM 1193
REV. 11-26-34
PHYSICAL EXAMINATION
(Follow instructions at end of form in answering all questions)
1. Name of applicant
havinia Fulton
Address 10 Staughton 58
City
Boston
State mass
2. Age
25
Height
H 3 in
Weight
121 lb
3.
General physique medium ling
4. Tendency to disease, inherited or otherwise
O
5. Previous history in regard to illness or injury no sudde few,
rhematic five, personania Hal meds, chake pis, influenger
6. Vision: Right eye; Distant vision 20/20 Corrected to - Lens used -
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. Hearing: Right ear; Watch /40" B
Whispered voice 3amel /15'
Left ear; Watch harmal /40"
Whispered voice hamal /15'
8. Teeth and gums: (note abnormalities) In good condition - visits dentil regularly
NOTE:-Check chart on other side of blank.
9. Neck: (thyroid glands and other abnormalities) not enlerged no
pulpuble glands
10. Spine and extremities: (bones, joints, muscles and feet) no servings w
kyphesis 1 m abnormal finding
11. Thorax: Respiratory system, bronchi, lungs, pleura, etc.
Expiration
34
inches
Inspiration
36"
inches
Respiration 18
per minute
Cardio-vascular system
Heart: (note all signs of cardiac involvement) hd Inleyed,
rute regular, m mumus hand
Pulse 70 Blood pressure: S 118
D
76
(Over)
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"ocrText": "THE AMERICAN RED CROSS NURSING SERVICE\nFORM 1193\nREV. 11-26-34\nPHYSICAL EXAMINATION\n(Follow instructions at end of form in answering all questions)\n1. Name of applicant\nhavinia Fulton\nAddress 10 Staughton 58\nCity\nBoston\nState mass\n2. Age\n25\nHeight\nH 3 in\nWeight\n121 lb\n3.\nGeneral physique medium ling\n4. Tendency to disease, inherited or otherwise\nO\n5. Previous history in regard to illness or injury no sudde few,\nrhematic five, personania Hal meds, chake pis, influenger\n6. Vision: Right eye; Distant vision 20/20 Corrected to - Lens used -\nLeft eye; Distant vision 20/20 Corrected to - Lens 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. Hearing: Right ear; Watch /40\" B\nWhispered voice 3amel /15'\nLeft ear; Watch harmal /40\"\nWhispered voice hamal /15'\n8. Teeth and gums: (note abnormalities) In good condition - visits dentil regularly\nNOTE:-Check chart on other side of blank.\n9. Neck: (thyroid glands and other abnormalities) not enlerged no\npulpuble glands\n10. Spine and extremities: (bones, joints, muscles and feet) no servings w\nkyphesis 1 m abnormal finding\n11. Thorax: Respiratory system, bronchi, lungs, pleura, etc.\nExpiration\n34\ninches\nInspiration\n36\"\ninches\nRespiration 18\nper minute\nCardio-vascular system\nHeart: (note all signs of cardiac involvement) hd Inleyed,\nrute regular, m mumus hand\nPulse 70 Blood pressure: S 118\nD\n76\n(Over)"
}