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DMR Form No. 29
THE AMERICAN RED CROSS
CENTRAL DIVISION HEADQUARTERS
180 NORTH WABASH AVENUE
CHICAGO, ILL.
NURSING SERVICE
PHYSICAL EXAMINATION
1. Name of applicant
Kathain Popke
Address Marden
City,
State
Man
2. Age
30
Height 5.7
Weight
200
3. General physique.
Entra frod;
how
4. Tendency to disease, inherited or otherwise
5. Previous history in regard to serious illness or surgical operation Hyphon free
from yr he Ill effect ho. his other
6. Has she had meumatism?
m no
7. Has she at present or has she ever had hernia?
8. Condition of teeth
food.
9. Condition of feet
very ford
10. Abdomen and contained organs
how
11. Chest and contained organs
hom
Expiration
39
inches.
Inspiration
43
inches.
home
12. Vision O. D.
Hearing: A. D.
O. S flaps
A. S
human
NOTE: In case of refractive error state degree of correction by glasses.
13. Urine examination:
Color Light
Reaction
his
Specific gravity
1018.
Albumen
now
Casts
home
Leucocytes
now
Sugar.
home
14. Do you recommend applicant for:
(a) General hospital service.
yo.
(b) Tropical service
OK
15. Fill in location of base hospital, unit or detachment with which service is desired:
eite
Army base hospital at
Naval base hospital at
Emergency detachment at
Navy detachment at
Hospital unit at
Path Hard think
Surgical section at
M. D.
che
Date May 1-1 no
Address
Mondean Are
All questions MUST be answered; otherwise certificate will not be accepted at headquarters.
To be forwarded to Chief Nurse of Unit or to Committee Organizing Detachment.
Req. 17-833-1-3-18-20M
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"ocrText": "DMR Form No. 29\nTHE AMERICAN RED CROSS\nCENTRAL DIVISION HEADQUARTERS\n180 NORTH WABASH AVENUE\nCHICAGO, ILL.\nNURSING SERVICE\nPHYSICAL EXAMINATION\n1. Name of applicant\nKathain Popke\nAddress Marden\nCity,\nState\nMan\n2. Age\n30\nHeight 5.7\nWeight\n200\n3. General physique.\nEntra frod;\nhow\n4. Tendency to disease, inherited or otherwise\n5. Previous history in regard to serious illness or surgical operation Hyphon free\nfrom yr he Ill effect ho. his other\n6. Has she had meumatism?\nm no\n7. Has she at present or has she ever had hernia?\n8. Condition of teeth\nfood.\n9. Condition of feet\nvery ford\n10. Abdomen and contained organs\nhow\n11. Chest and contained organs\nhom\nExpiration\n39\ninches.\nInspiration\n43\ninches.\nhome\n12. Vision O. D.\nHearing: A. D.\nO. S flaps\nA. S\nhuman\nNOTE: In case of refractive error state degree of correction by glasses.\n13. Urine examination:\nColor Light\nReaction\nhis\nSpecific gravity\n1018.\nAlbumen\nnow\nCasts\nhome\nLeucocytes\nnow\nSugar.\nhome\n14. Do you recommend applicant for:\n(a) General hospital service.\nyo.\n(b) Tropical service\nOK\n15. Fill in location of base hospital, unit or detachment with which service is desired:\neite\nArmy base hospital at\nNaval base hospital at\nEmergency detachment at\nNavy detachment at\nHospital unit at\nPath Hard think\nSurgical section at\nM. D.\nche\nDate May 1-1 no\nAddress\nMondean Are\nAll questions MUST be answered; otherwise certificate will not be accepted at headquarters.\nTo be forwarded to Chief Nurse of Unit or to Committee Organizing Detachment.\nReq. 17-833-1-3-18-20M"
}