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FORM 1193
REV. FEB. 1941
AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(All questions must be answered by definite statements)
1. Name of applicant
GENEVIEUE Leprestre
Address 2334 N.W. Northrey City Portland State OrEgon
2. Age 41
Height 5'2'1"
Weight 1133/4
(feet and inches)
3. Family history Father diet of Century
4.
Past history: General health, operation, injury, any illnesses (Indicate dates) Tonsiffectomy - 1928;
Appendectomy 1930 Hysterectomy-1978;
5. General physique
Good
LL. eye 20/15/
Rt. eye 20/1st
{
Rt. 20/15
Rt none
6. Distant Vision: Without glasses
With glasses
Evidence of disease
(Lt. 20/15f
Lt. none
Note: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
(Rt. ear OK20 ft.)
(Rt. none
7. Hearing: (Whispered voice)
(Lt. ear O.K20 ft.)
Evidence of disease
(Lt. none
8.
Teeth and gums: (Note abnormalities) Gums and teeth in five Condition
Lower it 5 missing. its.
Directions: Indicate as follows-
Right
Applicant's
Left
X
Missing tooth
Teeth:
UX
7654321
1234567X
Lx 176X4321
1234567
Bridgework
Crown
beno
"Plate"-write out word to indicate plate.
9. Nose and Throat
norm. out.
10.
Neck: (Thyroid gland and other abnormalities) normal thyroid end nook
11. Skeletal: (Bones, joints, muscles and feet) norme/
12. Thorax: Expiration
3 1 3/4 inches
Inspiration
32 1/4 inches
20
Respiration ma per
minute
Lungs to percussion and auscultation nor
Cardio-vascular system normal
Heart: Size normal
Murmurs none
Pulse 82 Blood pressure: S 108 D 68
Regular
(Over)
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"ocrText": "FORM 1193\nREV. FEB. 1941\nAMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(All questions must be answered by definite statements)\n1. Name of applicant\nGENEVIEUE Leprestre\nAddress 2334 N.W. Northrey City Portland State OrEgon\n2. Age 41\nHeight 5'2'1\"\nWeight 1133/4\n(feet and inches)\n3. Family history Father diet of Century\n4.\nPast history: General health, operation, injury, any illnesses (Indicate dates) Tonsiffectomy - 1928;\nAppendectomy 1930 Hysterectomy-1978;\n5. General physique\nGood\nLL. eye 20/15/\nRt. eye 20/1st\n{\nRt. 20/15\nRt none\n6. Distant Vision: Without glasses\nWith glasses\nEvidence of disease\n(Lt. 20/15f\nLt. none\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\n(Rt. ear OK20 ft.)\n(Rt. none\n7. Hearing: (Whispered voice)\n(Lt. ear O.K20 ft.)\nEvidence of disease\n(Lt. none\n8.\nTeeth and gums: (Note abnormalities) Gums and teeth in five Condition\nLower it 5 missing. its.\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nX\nMissing tooth\nTeeth:\nUX\n7654321\n1234567X\nLx 176X4321\n1234567\nBridgework\nCrown\nbeno\n\"Plate\"-write out word to indicate plate.\n9. Nose and Throat\nnorm. out.\n10.\nNeck: (Thyroid gland and other abnormalities) normal thyroid end nook\n11. Skeletal: (Bones, joints, muscles and feet) norme/\n12. Thorax: Expiration\n3 1 3/4 inches\nInspiration\n32 1/4 inches\n20\nRespiration ma per\nminute\nLungs to percussion and auscultation nor\nCardio-vascular system normal\nHeart: Size normal\nMurmurs none\nPulse 82 Blood pressure: S 108 D 68\nRegular\n(Over)"
}