121

Blank No. 14 Series II. Form B. 4.

II. Yourself: 1 - date of birth? 1849
2 - Early life in city or country? Town
3 - height? 5 ft 4 in
4 - weight? 124
5 - complexion? fair
6 - temperment?
7 - where educated, give degrees if any? [N?]. F. S. Oxford O. B. A.
8 - Occupations before marriage? a) in city or country? b) time
spent in each? Teaching - Cities & towns.

9 - diseases in your family? from father or mother's side?
Nervous Disorders? Rheumatism? Consumption? Dyspepsia?
Varicose Veins? Heart Disease? Hernia? Habitual Constipation?
Catarrh? Constipation - From both sides

10 - General health before marriage? b) since marriage?
Paralysis? Brain Fever? Chronic Headache? Nervous Prostation?
Catarrh? Hernia? Dispepsia? Habitual Constipation? Inflammation
of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting
Blood? Consumption? Laryngitis? Tonsilitis? Insomnia?
Rheumatism? Pneumonia? Jaundice? Varicose Veins?
Have never had any chronic disorder -
Health generally good both before and since marriage.

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Blank No. 14 Series II. Form B. 4.

II. Yourself:
1 - date of birth? 1849
2 - early life in city or country? town
3 - height? 5 ft 4 in
4 - weight? 124
5 - complexion? fair
6 - temperment?
7 - where educated, give degrees if any? [?] Oxford [?] B. A.
8 - occupations before marriage? a) in city or country? b) time spent in each? teaching. cities & towns.
9 - diseases in your family? from father or mother's side? Nervous Disorders? Rheumatism? Consumption? Dyspepsia? Varicose Veins? Heart Disease? Hernia? Habitual Constipation? Catarrh? Constipation - from both sides
10 - General health before marriage? [b)?] since marriage? Paralysis? Brain Fever? Chronic Headache? Nervous Prostation? Catarrh? Hernia? Dispepsia? Habitual Constipation? Inflammation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose Veins? Have never had any chronic disorder - Health generally good both before and since marriage.

-227-