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M
I
a
T
,
T
st
5
1.
X
6. Distant vision: This must be obtained by testing with Snellen Vision Chart at 20-foot distance and recorded
as a fraction, the numerator of which is the distance and the denominator the line on the
chart read at 20 feet.
G
(Right eye 20/20
(Right eye 20/
of
B
Without glasses
With glasses, if worn
Left eye 20/20
Left eye 20/
7. Ears and Hearing: Do you have a perforated ear drum? no
Do you have any impairment of hearing? Yes
No no
If so, specify degree-Slight
Moderate
Marked
8. Teeth: Gums healthy (Condition)
Cavities none (How many) filling
quetmany
Indicate on the chart below, the following conditions:
Missing teeth by X
Bridge work by
Plate-write out the word "plate" and indicate whether upper or lower
Your right
Your left
Upper
7 6 x 4 3 2 1
1 2 3 4 5 6 7
Upper
Lower
7 6 5 4 3 2 1
1 2 3 4 5 6 7
Lower
9. Date of immunization against Smallpox Bet. 1923 - 1926
Typhoid Bet. 1923-1926.
Have you been immunized against Tetanus? no
When
Diphtheria? Bet-1923-1926
"
Scarlet fever ?
"
Date and result of last Schick test
Negative
Positive
Date and result of last Dick test
Negative
Positive
10. What is your present physical condition ? Very good
If any disabilities, please specify none
sept 24, (Date) 1942
Bertha murply (Signature)
I
I
10,
This form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for
enrollment.
9
6
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"ocrText": "M\nI\na\nT\n,\nT\nst\n5\n1.\nX\n6. Distant vision: This must be obtained by testing with Snellen Vision Chart at 20-foot distance and recorded\nas a fraction, the numerator of which is the distance and the denominator the line on the\nchart read at 20 feet.\nG\n(Right eye 20/20\n(Right eye 20/\nof\nB\nWithout glasses\nWith glasses, if worn\nLeft eye 20/20\nLeft eye 20/\n7. Ears and Hearing: Do you have a perforated ear drum? no\nDo you have any impairment of hearing? Yes\nNo no\nIf so, specify degree-Slight\nModerate\nMarked\n8. Teeth: Gums healthy (Condition)\nCavities none (How many) filling\nquetmany\nIndicate on the chart below, the following conditions:\nMissing teeth by X\nBridge work by\nPlate-write out the word \"plate\" and indicate whether upper or lower\nYour right\nYour left\nUpper\n7 6 x 4 3 2 1\n1 2 3 4 5 6 7\nUpper\nLower\n7 6 5 4 3 2 1\n1 2 3 4 5 6 7\nLower\n9. Date of immunization against Smallpox Bet. 1923 - 1926\nTyphoid Bet. 1923-1926.\nHave you been immunized against Tetanus? no\nWhen\nDiphtheria? Bet-1923-1926\n\"\nScarlet fever ?\n\"\nDate and result of last Schick test\nNegative\nPositive\nDate and result of last Dick test\nNegative\nPositive\n10. What is your present physical condition ? Very good\nIf any disabilities, please specify none\nsept 24, (Date) 1942\nBertha murply (Signature)\nI\nI\n10,\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment.\n9\n6"
}