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Blank No. 8 Series II. Form B.

II. Yourself: 1 - date of birth? Feb 23, 1967 Dec 26 191[3?]
2 - Early life in city or country? until 18
3 - height? 5-4
4 - weight? 156
5 - complexion? dark
6 - temperament? nervous
7 - where educated, give degrees if any? Smith Col 3 yrs
8 - occupatins before marriage? a) in city or country? b) time
spent in each? Taught 1+ yrs
Tuter 1 yr
9 - diseases in your family? from father or mother's side?
nervous disorders? Rheumatism? Consumption? Dyspepsia?
Varicose Veins? Heart Disease? Hernia? Habitual Constipation?
Catarrh?
10 - General health before Marriage? [inserted]not robust better after going to college[inserted] b) since marriage? [??]
Paralysis? Brain Fever? Chronic Headache? Nervous Prostation?
Catarrh? Hernia? Dyspepsia? Habitual Constipation? Inflammation
of Bowels? Pleurisy? Bronchitis? Tonsilitis? Insomnia?
Rheumatism? Pneumonia? Jaundice? Varicose veins?
any other diseases?

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