187

Blank N. 22 Series II. Form B. 2.

(continued) 4 - Number of children? Eleven number reaching maturity? Eleven

Your Paternal Grandmother: home in city or country? Country.
1 - age when married? ---?
2 - Occupations? Housekeeping.
3 - health? Excellent.
4 - age and cause of death? ---?

Your Mother: 1 - Nationality, if American of what descent? Irish.
2 - home in city or country before marriage? City
b) home in city or country after marriage? City
3 - Occupations before her marriage? Teacher
b) after her marriage? Housekeeping.
4 - Note any prenatal influences before your birth. None
5 - her health previous to your birth? Excellent
b - after your birth? Excellent
6 - Number of miscarriages? Two, caused by
overwork.
7 - Her age if living and present health? if not, age at time
of death and cause? Sixty-four. Has heart-trouble
and is subject to intense emotional excitement
and melancholia.
8 - how was your mother's health affected by the climacteric
(change of life). The heart-trouble developed
together with periods of morbid emotional
excitement which have frequently to be quieted
by the use of morphine.
[in margin]climacteric began at 45 about[in margin]
9 - name any diseases in her family.

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