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18
MADIRIMA
D. Has the applicant ever suffered from any disease
D -
F. Has the applicant ever had any of the diseases
or functional derangement of the respiratory
us recurrence
of the digestive system? If yes, describe.
F appendectomy in 1914
system? If yes, state particulars.
Inquire particularly regarding appendicitis.
VI. The Genito-Urinary System.
VI.
E. What is the chest circumferecnce?
E 40
A. The specific gravity and reaction of the urine?
A 1008 acid.
Upon full inspiration?
42"
B. Is any albumen present, by heat and acid, or
B
No
38"
by Heller's test? Both tests required.
Upon full expiration?
III. The Circulatory System.
A. What is the temperature of the body?
(If
III. A 98°
C. Is any sugar present by Fehling's tests or by
C no
over 99° in the mouth, try another day.)
fermentation
-
D. Results of microscopic analysis, if necessary.
D
B. Give the rate and other qualities of the pulse.
B 100 - Good grading
E. Is there any derangment of the bladder?
E No
Record blood-pressure.
Cp 118-80
F. Of the kidneys?
F
"
C. Does it intermit, or become irregular or un-
C
No
VII. The Cutaneous System.
VII. negative
equal?
Has there ever been or is there any disease or
and
functional derangement of the system?
D. Does physical examination reveal anything
D No
whatever abnormal in the conditions of the
heart or blood vessels?
VIII. The Organs of Sense.
VIII.
A. The sight. Does the condition of the eyes in-
A Normal
dicate that they should be examined by a
E. Has the applicant ever suffered from any dis-
E No
specialist?
ease of the circulatory system? If yes, de-
B. The hearing. Any discharge from ears?
B Normal
scribe.
IV.
C. Other senses.
C Normal
IV. The Nervous System.
Has there ever been or is there any disease or
No
IX. Have there been any cases among the parents,
IX.
functional derangement of the brain or other
brothers or sisters of the applicant of
parts of the nervous system? If yes, state
A. Consumption?
A No
particulars. Inquire particularly regarding
headaches, insomnia, nervous exhaustion,
B. Insanity ?
B No
chorea or epilepsy and insanity.
C. Is there any predisposition hereditary or ac-
C. Faster died of diabetis (87)
quired, to gout, rheumatism, cancer, arterial
V. The Digestive System.
V.
negative
disease, diabetes, or nervous disorders, es-
pecially headaches, insomnia, nervous ex-
Has the applicant any disease or functional de-
haustion, chorea or epilepsy? If yes, state
rangement?
nature.
A
No
A. Of the stomach?
'1
X A. If the applicant is a woman, is she now suf-
X. A Negatial
B. Of the intestines?
B
fering or has she ever suffered from uterine
or menstrual disorder. (It is desirable that
C. Of the liver?
C 11
particular attention be given to this inquiry
D. Has there been or is there any tendency to
"
as the climate overseas bears heavily on those
D
thus affected.)
chronic constipation?
E. To diarrhea?
E
a
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"ocrText": "mleceoes\n18\nMADIRIMA\nD. Has the applicant ever suffered from any disease\nD -\nF. Has the applicant ever had any of the diseases\nor functional derangement of the respiratory\nus recurrence\nof the digestive system? If yes, describe.\nF appendectomy in 1914\nsystem? If yes, state particulars.\nInquire particularly regarding appendicitis.\nVI. The Genito-Urinary System.\nVI.\nE. What is the chest circumferecnce?\nE 40\nA. The specific gravity and reaction of the urine?\nA 1008 acid.\nUpon full inspiration?\n42\"\nB. Is any albumen present, by heat and acid, or\nB\nNo\n38\"\nby Heller's test? Both tests required.\nUpon full expiration?\nIII. The Circulatory System.\nA. What is the temperature of the body?\n(If\nIII. A 98°\nC. Is any sugar present by Fehling's tests or by\nC no\nover 99° in the mouth, try another day.)\nfermentation\n-\nD. Results of microscopic analysis, if necessary.\nD\nB. Give the rate and other qualities of the pulse.\nB 100 - Good grading\nE. Is there any derangment of the bladder?\nE No\nRecord blood-pressure.\nCp 118-80\nF. Of the kidneys?\nF\n\"\nC. Does it intermit, or become irregular or un-\nC\nNo\nVII. The Cutaneous System.\nVII. negative\nequal?\nHas there ever been or is there any disease or\nand\nfunctional derangement of the system?\nD. Does physical examination reveal anything\nD No\nwhatever abnormal in the conditions of the\nheart or blood vessels?\nVIII. The Organs of Sense.\nVIII.\nA. The sight. Does the condition of the eyes in-\nA Normal\ndicate that they should be examined by a\nE. Has the applicant ever suffered from any dis-\nE No\nspecialist?\nease of the circulatory system? If yes, de-\nB. The hearing. Any discharge from ears?\nB Normal\nscribe.\nIV.\nC. Other senses.\nC Normal\nIV. The Nervous System.\nHas there ever been or is there any disease or\nNo\nIX. Have there been any cases among the parents,\nIX.\nfunctional derangement of the brain or other\nbrothers or sisters of the applicant of\nparts of the nervous system? If yes, state\nA. Consumption?\nA No\nparticulars. Inquire particularly regarding\nheadaches, insomnia, nervous exhaustion,\nB. Insanity ?\nB No\nchorea or epilepsy and insanity.\nC. Is there any predisposition hereditary or ac-\nC. Faster died of diabetis (87)\nquired, to gout, rheumatism, cancer, arterial\nV. The Digestive System.\nV.\nnegative\ndisease, diabetes, or nervous disorders, es-\npecially headaches, insomnia, nervous ex-\nHas the applicant any disease or functional de-\nhaustion, chorea or epilepsy? If yes, state\nrangement?\nnature.\nA\nNo\nA. Of the stomach?\n'1\nX A. If the applicant is a woman, is she now suf-\nX. A Negatial\nB. Of the intestines?\nB\nfering or has she ever suffered from uterine\nor menstrual disorder. (It is desirable that\nC. Of the liver?\nC 11\nparticular attention be given to this inquiry\nD. Has there been or is there any tendency to\n\"\nas the climate overseas bears heavily on those\nD\nthus affected.)\nchronic constipation?\nE. To diarrhea?\nE\na"
}