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THE AMERICAN RED CROSS NURSING SERVICE
FORM 1193
REV. 11-26-34
PHYSICAL EXAMINATION
(Follow instructions at end of form in answering all questions)
R
1. Name of applicant mins Bounth Laxton
&
Address state opportment.shated Charlnton State 2/Va
+
C Rynnn Weight 114
5
2. Age 39
Height
3. General physique Hindur inst
4. Tendency to disease, inherited or otherwise
no history of
Inductable or athes chronic cond, Father did of mephrited
5. Previous history in regard to illness or injury artomstill audunt
one mas age no fracture or
Palls mylics agr of the that youright by -
6. Vision: Right eye; Distant vision 20/2 Corrected to
Lens used
-
-
Left eye; Distant vision 10/10 Corrected to
Lens used
NOTE:-Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.
If glasses are worn state correction.
7. Hearing: Right ear; Watch
20 /40"
Whispered voice
20/15'
Left ear; Watch
no /40"
Whispered voice
no /15'
8. Teeth and gums: (note abnormalities guns dealthy
NOTE-Check chart on other side of blank.
9. Neck: (Thyroid glands and other abnormalities) no annommeding
mo mlargement
10.
and extremities: (bones, joints muscles and feet) Afine normal
some Spine shift -him might hg due to early Palio had
mmenlal no suffer inste important
11. Thorax: Respiratory system, bronchi, lungs, pleura, etc no
Expiration 29
inches
Inspiration I2
inches
I
Respiration
18
per minute
Cardio-vascular system
normal
Heart: (note all signs of cardiac involvement) MD abnomalitar
of heart
Pulse 80 Blood pressure: S. 110
D. 62
(over)
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"ocrText": "a\nx\nTHE AMERICAN RED CROSS NURSING SERVICE\nFORM 1193\nREV. 11-26-34\nPHYSICAL EXAMINATION\n(Follow instructions at end of form in answering all questions)\nR\n1. Name of applicant mins Bounth Laxton\n&\nAddress state opportment.shated Charlnton State 2/Va\n+\nC Rynnn Weight 114\n5\n2. Age 39\nHeight\n3. General physique Hindur inst\n4. Tendency to disease, inherited or otherwise\nno history of\nInductable or athes chronic cond, Father did of mephrited\n5. Previous history in regard to illness or injury artomstill audunt\none mas age no fracture or\nPalls mylics agr of the that youright by -\n6. Vision: Right eye; Distant vision 20/2 Corrected to\nLens used\n-\n-\nLeft eye; Distant vision 10/10 Corrected to\nLens used\nNOTE:-Actual vision should be determined on proper letters for 20 foot distant, as 20-20, 20-30, 20-100, etc.\nIf glasses are worn state correction.\n7. Hearing: Right ear; Watch\n20 /40\"\nWhispered voice\n20/15'\nLeft ear; Watch\nno /40\"\nWhispered voice\nno /15'\n8. Teeth and gums: (note abnormalities guns dealthy\nNOTE-Check chart on other side of blank.\n9. Neck: (Thyroid glands and other abnormalities) no annommeding\nmo mlargement\n10.\nand extremities: (bones, joints muscles and feet) Afine normal\nsome Spine shift -him might hg due to early Palio had\nmmenlal no suffer inste important\n11. Thorax: Respiratory system, bronchi, lungs, pleura, etc no\nExpiration 29\ninches\nInspiration I2\ninches\nI\nRespiration\n18\nper minute\nCardio-vascular system\nnormal\nHeart: (note all signs of cardiac involvement) MD abnomalitar\nof heart\nPulse 80 Blood pressure: S. 110\nD. 62\n(over)"
}