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THE AMERICAN RED CROSS NURSING SERVICE
FORM 1193
REV. 11-9-33
PHYSICAL EXAMINATION
(Follow instructions at end of form in answering all questions)
1. Name of applicant Elizabeth me Coy
Address apt 70- Cincinnoti State Ohio
2. Age 95
Height 5'3"
Weight 132
3. General physique very good
4. Tendency to disease, inherited or otherwise
none
5. Previous history in regard to illness or injury no
6. Vision: Right eye; Distant vision tw 20/- Corrected to 20 By get66-900
5th +25
Left eye; Distant vision 2/10- no Corrected to w By ph+25
no
R glasses for close work-
Getso-105"
NOTE:-Actual vision 'should be determined on proper letters for 20 foot distance, as, 20-20, 20-30,20-100, etc.
If glasses are worn state correction.
7. Hearing: Right ear; Watch
40 /40"
B
Whispered voice
15/15
Left ear; Watch
40.40
Whispered voice
15 /15
8. Teeth and gums: (note abnormalities) none
NOTE:-Check chart on other side of blank.
9. Neck: (Thyroid glands and other abnormalities)
normal
10. Spine and extremities: (bones, joints, muscles and feet) normal
11. Thorax: Respiratory system, bronchi, lungs, pleura, etc. normal
Expiration 30
inches
Inspiration
34% inches
Respiration
4
11
inches
12
Cardio-vascular normal
system
Heart: (note all signs of cardiac involvement) sounds
normal a
TS
Pulse 74 Blood pressure: S
68
ATBOGL9
D
Over
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"ocrText": "THE AMERICAN RED CROSS NURSING SERVICE\nFORM 1193\nREV. 11-9-33\nPHYSICAL EXAMINATION\n(Follow instructions at end of form in answering all questions)\n1. Name of applicant Elizabeth me Coy\nAddress apt 70- Cincinnoti State Ohio\n2. Age 95\nHeight 5'3\"\nWeight 132\n3. General physique very good\n4. Tendency to disease, inherited or otherwise\nnone\n5. Previous history in regard to illness or injury no\n6. Vision: Right eye; Distant vision tw 20/- Corrected to 20 By get66-900\n5th +25\nLeft eye; Distant vision 2/10- no Corrected to w By ph+25\nno\nR glasses for close work-\nGetso-105\"\nNOTE:-Actual vision 'should be determined on proper letters for 20 foot distance, as, 20-20, 20-30,20-100, etc.\nIf glasses are worn state correction.\n7. Hearing: Right ear; Watch\n40 /40\"\nB\nWhispered voice\n15/15\nLeft ear; Watch\n40.40\nWhispered voice\n15 /15\n8. Teeth and gums: (note abnormalities) none\nNOTE:-Check chart on other side of blank.\n9. Neck: (Thyroid glands and other abnormalities)\nnormal\n10. Spine and extremities: (bones, joints, muscles and feet) normal\n11. Thorax: Respiratory system, bronchi, lungs, pleura, etc. normal\nExpiration 30\ninches\nInspiration\n34% inches\nRespiration\n4\n11\ninches\n12\nCardio-vascular normal\nsystem\nHeart: (note all signs of cardiac involvement) sounds\nnormal a\nTS\nPulse 74 Blood pressure: S\n68\nATBOGL9\nD\nOver"
}