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M
FORM 1193
REV. FEB. 1941
AMERICAN RED CROSS NURSING SERVICE
are
PHYSICAL EXAMINATION
R
(All questions must be answered by definite statements)
1.
Name of applicant imme Reba Elizabeth
Address 2136 Fultors St, Apt.
4
City Toledo
State Ohip
2. Age
Height 5'6"
195 + 57 + 34
a
Weight
(feet and inches)
(pounds)
3. Family
history Parents living in good health
E
4. Past history: General health, operation, injury, any illnesses (Indicate dates) Good no operations
=
Gall bladder disturbace march 1937
2
5. General physique Obese
a
(Rt. eye 20/20
(Rt. 20/
6. Distant Vision: Without glasses
With glasses
(Lt. eye 20/20)
(Lt. 20/
the
(Rt
none
Evidence of disease
(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 /20 ft.
(Rt.
none
7. Hearing: (Whispered voice)
Evidence of disease
(Lt. ear /20 ft.
LL
none
8. Teeth and gums: (Note abnormalities)
Good
Directions: Indicate as follows-
Right
Applicant's
Left
Missing tooth
U8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
Teeth:
L8 7 6 5 4 3 2 1
1 2 3 4 5 6 X 8
Bridgework
Crown
"Plate"-write out word to indicate plate.
IF sop pAbs of quit (o bsyom
9. Nose and Throat
10. Neck: (Thyroid gland and other abnormalities)
11. Skeletal: (Bones, joints, muscles and feet)
18
12. Thorax: Expiration
inches
Inspiration
inches
I
Respiration
per minute
D
Lungs to percussion and auscultation
Cardio-vascular system
Heart: Size
(preyse)
-
-
Murmurs
a
Pulse
13°
Blood pressure: S
D
(Over)
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"ocrText": "M\nFORM 1193\nREV. FEB. 1941\nAMERICAN RED CROSS NURSING SERVICE\nare\nPHYSICAL EXAMINATION\nR\n(All questions must be answered by definite statements)\n1.\nName of applicant imme Reba Elizabeth\nAddress 2136 Fultors St, Apt.\n4\nCity Toledo\nState Ohip\n2. Age\nHeight 5'6\"\n195 + 57 + 34\na\nWeight\n(feet and inches)\n(pounds)\n3. Family\nhistory Parents living in good health\nE\n4. Past history: General health, operation, injury, any illnesses (Indicate dates) Good no operations\n=\nGall bladder disturbace march 1937\n2\n5. General physique Obese\na\n(Rt. eye 20/20\n(Rt. 20/\n6. Distant Vision: Without glasses\nWith glasses\n(Lt. eye 20/20)\n(Lt. 20/\nthe\n(Rt\nnone\nEvidence of disease\n(Lt.\nnone\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\n(Rt. ear /20 ft.\n(Rt.\nnone\n7. Hearing: (Whispered voice)\nEvidence of disease\n(Lt. ear /20 ft.\nLL\nnone\n8. Teeth and gums: (Note abnormalities)\nGood\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nMissing tooth\nU8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8\nTeeth:\nL8 7 6 5 4 3 2 1\n1 2 3 4 5 6 X 8\nBridgework\nCrown\n\"Plate\"-write out word to indicate plate.\nIF sop pAbs of quit (o bsyom\n9. Nose and Throat\n10. Neck: (Thyroid gland and other abnormalities)\n11. Skeletal: (Bones, joints, muscles and feet)\n18\n12. Thorax: Expiration\ninches\nInspiration\ninches\nI\nRespiration\nper minute\nD\nLungs to percussion and auscultation\nCardio-vascular system\nHeart: Size\n(preyse)\n-\n-\nMurmurs\na\nPulse\n13°\nBlood pressure: S\nD\n(Over)"
}