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THE AMERICAN RED CROSS NURSING SERVICE
FORM 1193
REV. 6-15-25
to
PHYSICAL EXAMINATION
(Follow instructions at foot of page in answering all questions)
1. Name of applicant
this Reha Brale
Badge No.
Address
15-E-34
City Indianapility State Indiana
K
2. Age
30.
Height Stim
3. General physique
Amall but good
Weight
96.
a
+
4. Tendency to disease, inherited or otherwise
5
None
T
+
5. Previous history in regard to serious illness or surgical operation Hernas (successful operating
S
6. Has she had rheumatism ?
to
7. Has she at present or has she ever had hernia ? yes.
B
8. Condition of teeth
9. Condition of Bones and Joints
good Aminal Ser back of ange
los ere
Flat Foot
Sho
10. Abdomen and contained organs
Normal
los
11. Chest and contained organs
Armul
de 93
Girth: Expiration
28 1/2
inches. Inspiration
30 1/2
inches
e
Respiration, rate of
16
Heart, pulse rate
80
Right eye (Snellen) 20/60
Corrected to lens used
12. Vision':
Left eye (Snellen) 20/40
Corrected to
Toh connector
Tehs used
NOTE.-- - Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50, 20-100, etc.
If glasses
13. Hearing: Right
are worn state correction 20/20
Left
20/20
Hearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.
14. Urine examination
Color thing
Reaction
acid
Specific gravity
1004
Albumen
No
Casts
No
Leucocytes
sto.
Sugar
to
15. Do you recommend applicant for active hospital service?
the
George Band M. D.
Date Dec. 11, , 1934
Address 608 Hum Waumm Bidy
All questions MUST be answered; otherwise certificate will not be accepted at Headquarters.
Indianapies
To be forwarded to the Local Committee on Red Cross Nursing Service.
1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.
5
2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.
8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.
8
9. Flat foot-state whether or not any inconvenience exists.
11. Chest measurements should be in total inches.
Page data
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- Source index
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- Media ID
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Document data
- ID
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- Core
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- Type
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"ocrText": "THE AMERICAN RED CROSS NURSING SERVICE\nFORM 1193\nREV. 6-15-25\nto\nPHYSICAL EXAMINATION\n(Follow instructions at foot of page in answering all questions)\n1. Name of applicant\nthis Reha Brale\nBadge No.\nAddress\n15-E-34\nCity Indianapility State Indiana\nK\n2. Age\n30.\nHeight Stim\n3. General physique\nAmall but good\nWeight\n96.\na\n+\n4. Tendency to disease, inherited or otherwise\n5\nNone\nT\n+\n5. Previous history in regard to serious illness or surgical operation Hernas (successful operating\nS\n6. Has she had rheumatism ?\nto\n7. Has she at present or has she ever had hernia ? yes.\nB\n8. Condition of teeth\n9. Condition of Bones and Joints\ngood Aminal Ser back of ange\nlos ere\nFlat Foot\nSho\n10. Abdomen and contained organs\nNormal\nlos\n11. Chest and contained organs\nArmul\nde 93\nGirth: Expiration\n28 1/2\ninches. Inspiration\n30 1/2\ninches\ne\nRespiration, rate of\n16\nHeart, pulse rate\n80\nRight eye (Snellen) 20/60\nCorrected to lens used\n12. Vision':\nLeft eye (Snellen) 20/40\nCorrected to\nToh connector\nTehs used\nNOTE.-- - Actual vision should be stated, determined on proper letters for 20 foot distance, as 20-20, 20-50, 20-100, etc.\nIf glasses\n13. Hearing: Right\nare worn state correction 20/20\nLeft\n20/20\nHearing should record whispered voice at 20 feet, as 20-20, 15-20, 10-20, etc.\n14. Urine examination\nColor thing\nReaction\nacid\nSpecific gravity\n1004\nAlbumen\nNo\nCasts\nNo\nLeucocytes\nsto.\nSugar\nto\n15. Do you recommend applicant for active hospital service?\nthe\nGeorge Band M. D.\nDate Dec. 11, , 1934\nAddress 608 Hum Waumm Bidy\nAll questions MUST be answered; otherwise certificate will not be accepted at Headquarters.\nIndianapies\nTo be forwarded to the Local Committee on Red Cross Nursing Service.\n1. Be sure that all items are filled in before forwarding. Make definite statements in all instances.\n5\n2. Give age in years, height in inches, weight in pounds, stating amount of clothing entering into weight.\n8. State what teeth are missing and existing dentistry, such as crowns, plates, etc. State number of opposed molars.\n8\n9. Flat foot-state whether or not any inconvenience exists.\n11. Chest measurements should be in total inches."
}