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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 Mins Ethel Kersey.
Address 24E High.
City Elijabettlew State Pa.
2. Age 35
Height 5'8"
Weight 135
3. General physique Good
4. Tendency to disease, inherited or otherwise none
5. Previous history in regard to illness or injury Dy-hotheria, Tonsilectomy
and affendectomy
6. Vision: Right eye; Distant vision 20 Corrected to
Lens used
20
Left eye; Distant vision 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
40/40"
Whispered voice
15/15
It
DOL'
arace
Left ear; Watch
40/40"
Whispered voice
16/15'
8. Teeth and gums: (note abnormalities)
none
NOTE-Check chart on other side of blank.
9. Neck: (Thyroid glands and other abnormalities) normal
10. Spine and extremities: (bones, joints, muscles and feet) normal
11. normal
Thorax: Respiratory system, bronchi, lungs, pleura, etc.
Expiration 32
inches
Inspiration 36 inches
Respiration 20
per minute
Cardio-vascular system normal
Heart: (note all signs of cardiac involvement) none
Pulse 74 Blood pressure: S 115 D. 78
(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 Mins Ethel Kersey.\nAddress 24E High.\nCity Elijabettlew State Pa.\n2. Age 35\nHeight 5'8\"\nWeight 135\n3. General physique Good\n4. Tendency to disease, inherited or otherwise none\n5. Previous history in regard to illness or injury Dy-hotheria, Tonsilectomy\nand affendectomy\n6. Vision: Right eye; Distant vision 20 Corrected to\nLens used\n20\nLeft eye; Distant vision 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. Hearing: Right ear; Watch\n40/40\"\nWhispered voice\n15/15\nIt\nDOL'\narace\nLeft ear; Watch\n40/40\"\nWhispered voice\n16/15'\n8. Teeth and gums: (note abnormalities)\nnone\nNOTE-Check chart on other side of blank.\n9. Neck: (Thyroid glands and other abnormalities) normal\n10. Spine and extremities: (bones, joints, muscles and feet) normal\n11. normal\nThorax: Respiratory system, bronchi, lungs, pleura, etc.\nExpiration 32\ninches\nInspiration 36 inches\nRespiration 20\nper minute\nCardio-vascular system normal\nHeart: (note all signs of cardiac involvement) none\nPulse 74 Blood pressure: S 115 D. 78\n(Over)"
}