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FORM 1193
REV. 10-26-38
AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(Follow instructions at end of form in answering all questions)
1. Name of applicant Powell KERFOOT, D. PAULINE
Address ROUTE # 2
City
Caldwell
State
Idaho
CD
--
2. Age
22.
Height
blinches Weight 110 pounds
3. Family history negative
4. Past history: General any
health, operation, injury, illnesses Too d health
5. General physique good
K
T
6. Eyes: Pupils; Right eye; Distant vision 20/30 Corrected to 20/20 Lens used t 25+25
er
1
a
ax 105
Left eye; Distant vision 30/30 Corrected to 20/20 Lens used +25+50
f
E
ax 7o
0
NOTE: - Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
If glasses are worn state correction.
+
e
7. Ears: Normal
P
K
8. Teeth and gums: (note abnormalitie Normal
e
1
NOTE:-Check chart on other side of blank.
to
9. Throat Chronic inf tmoik
0
0
10. Neck: (Thyroid gland and other abnormalities)
+
Simple benign enlargement not pathogenic,
-
11. Skeletal: (Bones, joints, muscles and feet) Normal
I
12. Thorax: Expiration
32'4
inches
Inspiration 30
inches
Respiration
18
per minute
Lungs to percussion and auscultation clear
001V103
Cardio-vascular system negative noannoxmalities
Heart: Size Normal - Toner normal
I
Murmurs normal
sera
Pulse 72
Blood pressure: S 112
D 50
1
(Over)
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"ocrText": "FORM 1193\nREV. 10-26-38\nAMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(Follow instructions at end of form in answering all questions)\n1. Name of applicant Powell KERFOOT, D. PAULINE\nAddress ROUTE # 2\nCity\nCaldwell\nState\nIdaho\nCD\n--\n2. Age\n22.\nHeight\nblinches Weight 110 pounds\n3. Family history negative\n4. Past history: General any\nhealth, operation, injury, illnesses Too d health\n5. General physique good\nK\nT\n6. Eyes: Pupils; Right eye; Distant vision 20/30 Corrected to 20/20 Lens used t 25+25\ner\n1\na\nax 105\nLeft eye; Distant vision 30/30 Corrected to 20/20 Lens used +25+50\nf\nE\nax 7o\n0\nNOTE: - Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\nIf glasses are worn state correction.\n+\ne\n7. Ears: Normal\nP\nK\n8. Teeth and gums: (note abnormalitie Normal\ne\n1\nNOTE:-Check chart on other side of blank.\nto\n9. Throat Chronic inf tmoik\n0\n0\n10. Neck: (Thyroid gland and other abnormalities)\n+\nSimple benign enlargement not pathogenic,\n-\n11. Skeletal: (Bones, joints, muscles and feet) Normal\nI\n12. Thorax: Expiration\n32'4\ninches\nInspiration 30\ninches\nRespiration\n18\nper minute\nLungs to percussion and auscultation clear\n001V103\nCardio-vascular system negative noannoxmalities\nHeart: Size Normal - Toner normal\nI\nMurmurs normal\nsera\nPulse 72\nBlood pressure: S 112\nD 50\n1\n(Over)"
}