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Blank No. 21 Series II. Form B. 4.

Yourself: 1 - date of birth? 1832
2 - Early life in [deleted]city or[deleted] country? until four years old in town & city since
3 - height? 5.1 1/2(?)
4 - weight? 102 or 3
5 - complexion? hair golden brown & brown eyes & light
6 - temperament? sanguine, nervous, anxious, melancholy
7 - where educated, give degrees if any? In So. Bend Ind. Academy.
8 - Occupations before marriage? a) in city or country? b) time
spent in each?
9 - diseases in your famly? from father or mother's side?
Nervous Disorders?[check-marked] Heart Disease?[check-marked], Hernia? Habitual Constipation?[check-marked]
Catarrh?[check-mark crossed out] father's side [??] catarrh in father's famly
10 - General health before marriage? b) since marriage?
Paralysis? Brain Fever? Chronic Headache? [inserted]nervous a little[inserted] Nervous Prostation?[check-marked]
Catarrh?[check-marked] Hernia? Dispepsia?[check-marked] Habitual Constipation?[check-marked] Inflammation
of Bowels? Pleurisy?[check-marked] Bronchitis? [inserted]?[inserted] Shortness of Breath?[check-marked twice] Spitting
Blood? Consumption? Laryngitis?[check-marked] Tonsilitis? Insomnia?[check-marked]
Rheumatism? Pneumonia?[check-marked] Jaundice? Varicose veins?

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