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HARVARD UNIT
FORM 1193
REV. JULY 1941
AMERICAN RED CROSS
A.R.C. MAIL
NURSING SERVICE
[OLUS 18 to pe
RECEIVED ROOM No.2
PHYSICAL EXAMINATION
MAY 21 1942
(All questions must be answered by definite statements) red
1. Name of applicant Mar jory Storey
Address 30 Hortense Street
City
Rochester
State to Marring New York
2. Age
43
Height
5 1 1/2
Weight
125
(feet and inches)
(pounds)
3. Family history / botther died tuberculisies 1915
4. Past history: General health, operation, injury, any illnesses (Indicate dates) Trusilectory 1926
searlet fever with nephritis in childhood general health good
5. General medium to Hender
physique
(Rt. eye 20/201
(Rt. 20/
(Rt no
6. Distant Vision: Without glasses
With glasses
Evidence of disease
(Lt. eye 20/30/
(Lt. 20 /
(Lt. no
Note: Actual vision should be determined on proper letters for 20 foot distant, as 20-20,20-30,20-100, etc.
7. Hearing: (Whispered voice) (Rt. Lt. ea ear 12/20 ft. 20/20 ft.
(Rt.
no
Evidence of disease
(Lt. no
8. Teeth and gums: (Note abnormalities) guns in good condition.
Directions: Indicate as follows-
Right
Applicant's
Left
Missing tooth
U8 X 6 5 4 3 2 1
1 2 3 4 5 6 X 8
Teeth:
Bridgework
LX 7 6 5 4 3 2 1
1 2 3 4 5 6 7
8
Crown
Drio
"Plate"-write out word to indicate plate.
Il nop que beujotur
9. Nose and Throat normal
gack
10. Neck: (Thyroid gland and other abnormalities) negative
11. Skeletal: (Bones, joints, muscles, and feet) normal
12. Thorax: Expiration
27 1/2
inches
Inspiration
29
inches
Respiration
18
per minute
Lungs to percussion and auscultation
clear
Cardio-vascular system
normal
Heart: Size
normal
Murmurs
none
FEB 4 - 1948
Pulse 80
Blood pressure: Syst. 138 Dias.
75
(OVER)
2
8
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"ocrText": "HARVARD UNIT\nFORM 1193\nREV. JULY 1941\nAMERICAN RED CROSS\nA.R.C. MAIL\nNURSING SERVICE\n[OLUS 18 to pe\nRECEIVED ROOM No.2\nPHYSICAL EXAMINATION\nMAY 21 1942\n(All questions must be answered by definite statements) red\n1. Name of applicant Mar jory Storey\nAddress 30 Hortense Street\nCity\nRochester\nState to Marring New York\n2. Age\n43\nHeight\n5 1 1/2\nWeight\n125\n(feet and inches)\n(pounds)\n3. Family history / botther died tuberculisies 1915\n4. Past history: General health, operation, injury, any illnesses (Indicate dates) Trusilectory 1926\nsearlet fever with nephritis in childhood general health good\n5. General medium to Hender\nphysique\n(Rt. eye 20/201\n(Rt. 20/\n(Rt no\n6. Distant Vision: Without glasses\nWith glasses\nEvidence of disease\n(Lt. eye 20/30/\n(Lt. 20 /\n(Lt. no\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20,20-30,20-100, etc.\n7. Hearing: (Whispered voice) (Rt. Lt. ea ear 12/20 ft. 20/20 ft.\n(Rt.\nno\nEvidence of disease\n(Lt. no\n8. Teeth and gums: (Note abnormalities) guns in good condition.\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nMissing tooth\nU8 X 6 5 4 3 2 1\n1 2 3 4 5 6 X 8\nTeeth:\nBridgework\nLX 7 6 5 4 3 2 1\n1 2 3 4 5 6 7\n8\nCrown\nDrio\n\"Plate\"-write out word to indicate plate.\nIl nop que beujotur\n9. Nose and Throat normal\ngack\n10. Neck: (Thyroid gland and other abnormalities) negative\n11. Skeletal: (Bones, joints, muscles, and feet) normal\n12. Thorax: Expiration\n27 1/2\ninches\nInspiration\n29\ninches\nRespiration\n18\nper minute\nLungs to percussion and auscultation\nclear\nCardio-vascular system\nnormal\nHeart: Size\nnormal\nMurmurs\nnone\nFEB 4 - 1948\nPulse 80\nBlood pressure: Syst. 138 Dias.\n75\n(OVER)\n2\n8"
}