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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.
Right eye 20/20
Left eye 20/20
{
Right eye 20/
Without glasses
With glasses, if worn
Left eye 20/
7. Do have perforated drum? no
Ears and Hearing: you a ear
Do you have any impairment of hearing? Yes.
No no
If so, specify degree-Slight
Moderate
Marked
8. Teeth: Gums Good
Cavities all
(Condition)
filled
(How many)
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
12468 Upper Plate
Your left
Upper 8765421
Lower 8X654321
12345X78 Lower
9. Date of immunization against Smallpox 1937
Typhoid
Have you been immunized against Tetanus?
no
When
Diphtheria
no
"
Scarlet fever? yes
"
1938
Date and result of last Schick test
1940
Negative X Positive
Date and result of last Dick test
1940
Negative x Positive
10. What condition? Land
is your present physical
If any disabilities, please specify
(Signature) R.N
(Date)
This form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for
enrollment.
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"ocrText": "6. 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.\nRight eye 20/20\nLeft eye 20/20\n{\nRight eye 20/\nWithout glasses\nWith glasses, if worn\nLeft eye 20/\n7. Do have perforated drum? no\nEars and Hearing: you a ear\nDo you have any impairment of hearing? Yes.\nNo no\nIf so, specify degree-Slight\nModerate\nMarked\n8. Teeth: Gums Good\nCavities all\n(Condition)\nfilled\n(How many)\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\n12468 Upper Plate\nYour left\nUpper 8765421\nLower 8X654321\n12345X78 Lower\n9. Date of immunization against Smallpox 1937\nTyphoid\nHave you been immunized against Tetanus?\nno\nWhen\nDiphtheria\nno\n\"\nScarlet fever? yes\n\"\n1938\nDate and result of last Schick test\n1940\nNegative X Positive\nDate and result of last Dick test\n1940\nNegative x Positive\n10. What condition? Land\nis your present physical\nIf any disabilities, please specify\n(Signature) R.N\n(Date)\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment."
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