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Blank No. 5 Series II. Form B. 3.
I - Your Maternal Grandfather: home in city or country?
1 - age when married?
2 - occupations? farmer & teacher
3 - health? - [deleted]died suddenly[deleted] Died suddenly at 64
4 - Number of children? 11 b) Number reaching maturity? 11
II - Your maternal grandmother: home in city or country?
1 - age when married?
2 - occupations?
3 - health? good
4 - age and cause of death? died suddenly [deleted]at [??][deleted] 81
III - Your husband: Nationality, if American, of what descent? French descent
1 - date of birth? 26 Oct. 1855
2 - early life in city or country?
3 - height? 6 - 3 1/2
4 - weight? 250
5 - muscular or weak?
6 - Where educated? degrees if any?
7 - If a college man, has he been athletic?
8 - Complexion?
9 - does he use tobacco?
11 - occupations?
12 - health? good, but has catarrah.
13 - diseases in his family: Nervous Disorders? Rheumatism? Consumption? Dyspepsia? Varicose veins? Heart Disease? Hernia? Habitual Constipation? Catarrh?
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Blank No. 5 Series II. Form B.
III - Yourself: 1. date of birth? Aug 10. 64
2 - Early life in city or country?
3 - height?
4 - weight?
5 - Complexion?
6 - temperament?
7 - Where educated, give degrees if any?
8 - Occupations before marriage? a) in city or country? b) time spent in each?
9 - diseases in your family? from father or mother's side? Nervous Disorders? Rheumatism? Consumption? Dyspepsia? Varicose [insert]Mother[insert] Veins? Heart Disease? Hernia? Habitual Constipation? Catarrah
10 - General health before marriage? b)Since marriage? Paralysis? Brain Fever? Chronic Headache? Nervous Prostation? Catarrh? Hernia? Dispepsia? habitual Constipation? Inflammate of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose veins? [???] Typhoid, Scarlet fever, measles etc [???]
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Blank No. 5 Series II. Form B. 5.
11 - Menstruation:
First menstruation at what age? and when thoroughly established 14 14
Present condition as regards menstruation ([??] 51 - reg) still
a) how frequent? 2 or 3 days over 4 wks
b) is it regular or not? fairly
c) amount? how many napkins? one per day
d) duration? five
e) pain or not? at what time as to the flow. first day.
f) is there any leucorrhoea (whites)? character? before marriage
amount? very little
constant [deleted]or occasional?[deleted]
in fall when in there [?] once 2 mo. & next fall [?] about 7 week & again [?] a variation at [??] her New York was gun in her teachng. now very nervous nally left [???] on that
g) - have you pain either frequently or habitually in the head, small of the back? abdomen or limbs? No
h) disease or trouble in Uterus (womb) or other pelvic organs?
i) habit of bowels; how often? once a day varies two or 3 hours.
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Blank No. 5 Series II. Form B. 6.
12 - What knowledge of sexual physiology had you before marriage? b) how did you obtain it?
13 - Number of times married. If more than once additional blanks will be furnished you to answer the following questions separately in regard to each marriage?
14 - Number of years married? 3
15 - Do you habitually sleep with your husband? b) what reasons for so doing or not? No. b) pleasanter, and more comfortable more [deleted]wholesome[deleted] healthful. Habit of both to sleep alone before marriage.
16 - Number of conceptions? 2 (1915 - 4
17 - Number of children? State in connection with each a) date of birth? b) sex? c) whether healthy or not? d) note any charactersitic and the cause. e) note either immediate or after effect on your health of the birth of each of your chldren. f) give time of first menstruation after birth of each child.
(1) 2. a) 25 June 91. b) girl c) yes. d) - e) - f) once 6 months after but not established. [??] about 8 months. not established in next summer.
(2) b) June 14 - '93 b) girl c) healthy d) - e)
(3) a) Jan. 28. '97 b) girl c) healthy d) develope back? trouble? if any [??] not tubercular, no symptoms (over)
e) No troubl. f) devl[?] enlarged legs - 10 days after.
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