Part 17

Will you kindly fill up the following form of Medical Certificate, returning it to the address given above.

Your communication will be received as strictly confidential.

It is urgently requested that Members' names and detachment numbers should be filled in legibly.

Yours faithfully,

MARGARET HEMPHILL

MEDICAL CERTIFICATE

1. Name

2. County No. of Detachment

3. How long have you been acquainted with her?

4. Have you attended her professionally?

5. For what complaint?

6. Is she intelligent and of active habits?

7. General health?

8. Has she flat feet, hammer-toe, or any other defect?

9. Is her vision good in each eye?

10. Is her hearing perfect?

11. Has she sound teeth, and if not, have they been properly attended to by a Dentist lately?

12. Has she shown any tendency to Rheumatism, Anaemia, Tuberculosis, or other illness?

13. When?

14. What?

15. Has she ever had influenza?

16. Does she suffer from headaches?

17. Any form of fits?

18. Heart disease or varicose veins?

19. Is she subject to any functional disturbance?

* * * * *

I have on the day of 191 seen and examined and hereby certify that she is apparently in good health, that she is not labouring under any deformity, and is, in my opinion, both physically and mentally competent to undertake duty in a Military Hospital, and is [*]A. Fit for General Service. B. Fit for Home Service only. C. Unfit.

Date (Signed) Address