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Blank No.28 Series II. Form B. 4.
VIII. Yourself: 1- Date of birth? 1844
2- Early life in city or country? Town [Harglades?]
3- Height? 5ft 2.5 in
4- Weight? 150
5- Complexion? Dull, blonde
6- temperament? nervous
7- Where educated, give degrees if any? [rather?] college
8- Occupations before marriage? a) in city or country? b)time spent in each?
a)teacher in country 6 mo.
9- Diseases in your family? From father or mother's side? Nervous disorders? Rheumatism? Consumption? Dyspepsia? Varicose Veins? Heart Disease? Hernia? Habitual Constipation? Catarrh?
Nervous disorders, rheumatism - [mother and father's side?], habitual constipation, catarrh
10- General health before marriage? b)Since marriage? Paralysis? Brain fever? Chronic Headache? Nervous Prostation? Catarrh? Hernia? Dyspepsia? Habitual Constipation? Inlamation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? [Spitting?] Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose Veins?
Good, not strong in early life. Nervous Prostation, Tonsilitis. [Married all her children?] until they [reached?] 16 mo. all [mind trouble?]