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Blank No.36 Series II. Form B.
VIII. Yourself: 1- Date of birth? 1864
2- Early life in city or country? [City?]
3- Height? 5ft 4 in
4- Weight? 142 lbs
5- Complexion? Light
6- Temperament?
7- Where educated, give degrees if any? College B.L.
8- Occupations before marriage? (a)In city or country? (b)Time spent in each? Taught six months in country - First child, born [two?] years after marriage. Father 27 years. Mother 22 years

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, Catarrh.

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?
(before) Catarrh, slight Bronchitis. Scarlet fever at 5 yrs, left with cough and [strengthened?] tendency [to?] consumption. Continued through girlhood outgrown by 22 years.