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Blank No. 16 B Series II. Form B. 4.

Yourself: 1. date of birth? July 6, 1865
2 - early life in city or country? country and small town.
3 - height?
4 - weight? 98 - 100
5 - complexion? brunette
6 - temperament? Nervous (inclined to gloomy)
7 - where educated, give degrees if any? high school
8 - Occupations before marriage? a) in city or country? b) time
spent in each? 4 yrs. deputy county treasurer. Town, county seat.
2 1/2 Deputy Clerk of Court.
9 - diseases in your family? from father or mother's side?
Nervous Disorders? Rheumatism? Cnsumption? Dyspepsia?
Varicose Veins? Heart Disease? Hernia? Habitual constipation?
Catarrh? Cessation of menstruation (3 of girls.)
(two girls about 30.) (about 22)
before marriage at all
10 - General health before marriage? b) since marriage?
Paralysis? Brain Fever? Chronic Headache? Nervous Prostation?
Catarrh?[check-marked] Hernia? Dispepsia? Habitual Constipation?[check-marked] [inserted]not constant[inserted] Inflammati
of Bowels? Pleurisy?[inserted]very young 5-10 yrs old[inserted] Bronchitis? Shortness of Breath? Spitting
Blood? Consumption? Laryngitis? Tonsilitis? Insomnia[check-marked][inserted]at times[inserted]
Rheumatism? Pneumonia? Jaundice? Varicose veins?

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