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D
FORM 1193
REV. FEB. 1941
AMERICAN RED CROSS NURSING SERVICE
PHYSICAL EXAMINATION
(All questions must be answered by definite statements)
1. Name of applicant Day, Ina Elthe
Address 433 Lincalue are
City Orange
State new Jersey
2. Age 25
Height 5'I
Weight 100
E
(feet and inches)
(pounds)
3. Family history
4. Past history: General health, operation, injury, any illnesses (Indicate dates) General Health
+
good no operations injuries or serious illness
5
e
5. General physique
(Rt. eye 20/
}
(Rt. 20/
6. Distant Vision: Without glasses
With glasses
(Lt. eye 20/
(Lt. 20/
to
(Rt
Evidence of disease
(Lt.
Note: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
Tus
(Rt. ear /20 ft.)
7. Hearing: (Whispered voice)
Evidence of disease
(Lt. ear /20 f
he (Rt.
8. Teeth and gums: (Note abnormalities)
Directions: Indicate as follows-
Right
Applicant's
Left
Missing tooth
U8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
Teeth:
L8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
Bridgework
Crown
D
"Plate"-write out word to indicate plate.
of qnçã apro 12 (o
9. Nose and Throat
10. Neck: (Thyroid gland and other abnormalities)
11. Skeletal: (Bones, joints, muscles and feet)
ou
I
12. Thorax: Expiration
inches
inches
I
Inspiration
Respiration
per minute
12
Lungs to percussion and auscultation
Cardio-vascular
Heart: Size
Murmurs
Pulse
Blood pressure: S
D
13
(Over)
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"ocrText": "D\nFORM 1193\nREV. FEB. 1941\nAMERICAN RED CROSS NURSING SERVICE\nPHYSICAL EXAMINATION\n(All questions must be answered by definite statements)\n1. Name of applicant Day, Ina Elthe\nAddress 433 Lincalue are\nCity Orange\nState new Jersey\n2. Age 25\nHeight 5'I\nWeight 100\nE\n(feet and inches)\n(pounds)\n3. Family history\n4. Past history: General health, operation, injury, any illnesses (Indicate dates) General Health\n+\ngood no operations injuries or serious illness\n5\ne\n5. General physique\n(Rt. eye 20/\n}\n(Rt. 20/\n6. Distant Vision: Without glasses\nWith glasses\n(Lt. eye 20/\n(Lt. 20/\nto\n(Rt\nEvidence of disease\n(Lt.\nNote: Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\nTus\n(Rt. ear /20 ft.)\n7. Hearing: (Whispered voice)\nEvidence of disease\n(Lt. ear /20 f\nhe (Rt.\n8. Teeth and gums: (Note abnormalities)\nDirections: Indicate as follows-\nRight\nApplicant's\nLeft\nMissing tooth\nU8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8\nTeeth:\nL8 7 6 5 4 3 2 1\n1 2 3 4 5 6 7 8\nBridgework\nCrown\nD\n\"Plate\"-write out word to indicate plate.\nof qnçã apro 12 (o\n9. Nose and Throat\n10. Neck: (Thyroid gland and other abnormalities)\n11. Skeletal: (Bones, joints, muscles and feet)\nou\nI\n12. Thorax: Expiration\ninches\ninches\nI\nInspiration\nRespiration\nper minute\n12\nLungs to percussion and auscultation\nCardio-vascular\nHeart: Size\nMurmurs\nPulse\nBlood pressure: S\nD\n13\n(Over)"
}