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M
I
a
a
,
1st
T
5
1.
X
Form 1193
Rev. March 1942
ct
AMERICAN RED CROSS
1
of
Report of Physical Condition of Nurse
(Please answer all questions completely and accurately)
+
Applicant can answer all questions herself, except number 6, with which she will need assistance.
1. Name murphy (Last)
Butha
Irene
(First)
(Middle)
2. Age 45
Height 5- 8 inches
Weight 164
pounds
3. Family history: Indicate, in the space opposite the disease, which member of your family, if any, has had
the following, and when. Cross out those which no one has had.
Tuberculosis
Were you a contact?
Cancer
Diabetes
\
Heart disease Father
Epilopsy
Mental illness
4. Past medical history: General health good
Operations-specify nature of, and year
Tonsillectomy June 1942
Stefested left hand 1924
Injuries-specify
Illnesses- cross out the ones which you have not had. Indicate the dates when you had the others:
Allergie conditions
Arthritic
Cancer
Communicable
diseases (specify) measles, mumps-whotping cough
Diabetes
Hay fever
Heart discase
Hypertension
Migraine
Nervous or mental
Rheumatic fever
Sinusitio
Have you ever had Pulmonary Tuberculosis? If so, when
no
Where did you cure?
I
Is the condition now arrested?
Have you ever had a suspected
I
Pulmonary Tuberculosis?
If so, when
Others-specify. Valley
5. General physique-cross out those which do not apply.
Frail
Good
Robust
Thin
Siender
Obese
OVER
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"ocrText": "M\nI\na\na\n,\n1st\nT\n5\n1.\nX\nForm 1193\nRev. March 1942\nct\nAMERICAN RED CROSS\n1\nof\nReport of Physical Condition of Nurse\n(Please answer all questions completely and accurately)\n+\nApplicant can answer all questions herself, except number 6, with which she will need assistance.\n1. Name murphy (Last)\nButha\nIrene\n(First)\n(Middle)\n2. Age 45\nHeight 5- 8 inches\nWeight 164\npounds\n3. Family history: Indicate, in the space opposite the disease, which member of your family, if any, has had\nthe following, and when. Cross out those which no one has had.\nTuberculosis\nWere you a contact?\nCancer\nDiabetes\n\\\nHeart disease Father\nEpilopsy\nMental illness\n4. Past medical history: General health good\nOperations-specify nature of, and year\nTonsillectomy June 1942\nStefested left hand 1924\nInjuries-specify\nIllnesses- cross out the ones which you have not had. Indicate the dates when you had the others:\nAllergie conditions\nArthritic\nCancer\nCommunicable\ndiseases (specify) measles, mumps-whotping cough\nDiabetes\nHay fever\nHeart discase\nHypertension\nMigraine\nNervous or mental\nRheumatic fever\nSinusitio\nHave you ever had Pulmonary Tuberculosis? If so, when\nno\nWhere did you cure?\nI\nIs the condition now arrested?\nHave you ever had a suspected\nI\nPulmonary Tuberculosis?\nIf so, when\nOthers-specify. Valley\n5. General physique-cross out those which do not apply.\nFrail\nGood\nRobust\nThin\nSiender\nObese\nOVER"
}