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Blank No. 26 Series II. Form B. 4.
VIII. Yourself: 1- Date of birth? Feb. 8, 1859
2- Early life in city or country? Country
3- Height? 5ft 3.5 in
4-Weight? 145
5- Complexion? Light
6- Temperament? Even
7- Where educated, give degrees if any? Wellesley College. B.A. '81.
8- Occupations before marriage? (a) in city or country? (b)time spent in each? Teacher, 2 yrs in country, 4 yrs in city.
9- Diseases in your family? From father or mother's side? Nervous Disorders? Rheumatism? Consumption? Dyspepsia? Varicose veins? Heart Disease? Hernia? Habitual Constipation? Catarrh?
Heart disease from father's side. Tendency to Dyspepsia from both sides.
10- General health before marriage? (b)Since marriage? Paralysis? Brain Fever? Chronic Headache? Nervous Prostation? Catarrh? Hernia? Dyspepsia? Habitual Constipation? Inflammation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose Veins?
a. Health good but not robust.
b. Health good but not robust.