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Blank No. March 28, 1920 Series II. Form B. 4.

VII. Yourself: 1. date of birth? 18th Dec. 1864
2 - Early life in city or country? country
3 - height? 5 ft 4 in
4 - weight? 125 (115 now[?]
5 - complexion? medium
6 - temperament? matter of fact
7 - where educated, give degrees if any? 2 yrs Cornell Univ.
married and student at Swarthmore[?].
8 - occupations before marriage? a) in city or country? b) time
spent in each? Teaching very short time
9 - diseases in your family? from father or mother's side?
Nervous Disorders? Rheumatism?[underlined] [inserted]Father[inserted] Consumption? Dyspesia?
Varicose Veins? Heart Disease? Hernia? Habitual Constipation?
Catarrh? Mother - died of cancer
10 - General health before marriage? [inserted]good. [?] not strong
clothes very bad -
Heavy & tight clothes.
Treated for [???]
after marriage -[inserted] b) since marriage?
Paralysis? Brain Fever? Chronic Headache? Nervous Prostation?
Catarrh? Hernia? Dispepsia? Habitual Constipation? Inflammation
of Bowels? Pleurisy? Bronchitis?[underlined] [inserted]3-4 times[inserted] Shortness of Breath? Spitting
Blood? Consumption? Laryngitis? Tonsilitis? Insomnia?
Rheumatism? Pneumonia? Jaundice? Varicose veins?
Corset and waist put on by doctor & clothes supported - began to feel
better.

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