66

Blank No. 6

Series II. [Form?] B.

II. Yourself: 1. date of birth? 1858. Jan 16
2 - early life in city or city or country? Country.
3 - height? 5 ft. 4 1/2 in.
4 - weight? 135 lb.
5 - complexion? Rather light.
6 temperament?
7 - where educated, give degrees if any? Studied three years in Ripon College.
8 - Occupations before marriage? a) in city or country b) time
spent in each? Taught five years in the city.

9 - diseases in your family? from father or mother's side?
nervous disorders? Rheumatism? Consumption? Dyspepsia? [underlined]
Varicose Veins? Heart Disease? [underlined] Hernia? Habitual Constipation? [underlined]
Catarrh? The underlined are from mother's side, asthma from father's side.
9.0 age of ^ your father at your birth, age of ^ your mother? How many children
older than yourself. Father was 57 yrs old, mother 39; there were
five children older than myself, the youngest 10 yrs olders.

10. General health before marriage? b) Since marriage?
Paralysis? Brain Fever? Chronic Headache? Nervous Prostation?
Catarrh? Hernia? Dispepsia? [underlined] Habitual Constipation? [underlined] Inflammation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting
Blood? Consumption? Laryngitis? Tonsilitis? Insomnia?
Rheumatism? Pneumonia? Jaundice? Varicose veins?
General health better since marriage.