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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.
vision
(Right eye 20/
Right eye 20/
Without glasses
With glasses, if worn
Left eye 20/
Left eye 20/
7. Ears and Hearing: Do you have a perforated ear drum? ho
a
Do you have any impairment of hearing? Yes
No.
If so, specify degree-Slight
Moderate
Marked
8. Teeth: Gums good
Cavities no
(Condition)
(How many)
5
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
Your left
Upper 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Upper
x
Lower 8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8 Lower
x
9. Date of immunization against smallpox 1930
Typhoid 1930
Have you been immunized against tetanus? no
When
Diphtheria? 1930
"
Scarlet fever? no
"
Date and result of last Schick test
Negative 1930 Positive
Date and result of last Dick test
Negative
Positive
10. What is your present physical condition ? good
If any disabilities, please specify
January s,1942 (Date)
Rela K. Beale
(Signature)
(gess)
W
I
gebout or yma
5
VWEMICYA VED CHG22
8
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": "B\n6. 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.\nvision\n(Right eye 20/\nRight eye 20/\nWithout glasses\nWith glasses, if worn\nLeft eye 20/\nLeft eye 20/\n7. Ears and Hearing: Do you have a perforated ear drum? ho\na\nDo you have any impairment of hearing? Yes\nNo.\nIf so, specify degree-Slight\nModerate\nMarked\n8. Teeth: Gums good\nCavities no\n(Condition)\n(How many)\n5\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\nYour left\nUpper 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Upper\nx\nLower 8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8 Lower\nx\n9. Date of immunization against smallpox 1930\nTyphoid 1930\nHave you been immunized against tetanus? no\nWhen\nDiphtheria? 1930\n\"\nScarlet fever? no\n\"\nDate and result of last Schick test\nNegative 1930 Positive\nDate and result of last Dick test\nNegative\nPositive\n10. What is your present physical condition ? good\nIf any disabilities, please specify\nJanuary s,1942 (Date)\nRela K. Beale\n(Signature)\n(gess)\nW\nI\ngebout or yma\n5\nVWEMICYA VED CHG22\n8\nThis form is to be forwarded to the Local Committee on Red Cross Nursing Service with the application for\nenrollment."
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