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Blank No.33 Series II. Form B.
VIII. Yourself: 1- Date of birth? Dec. 20, 1874
2- Early life in city or country? Small town until 10, a little larger town later.
3- Height? 5ft 5.5 inches
4- Weight? 136 lbs
5- Complexion? Light
6- Temperament? Rather high strung, nervous.
7- Where educated, give degrees if any? Public school. [S?] '95 A.B.
8- Occupations before marriage? (a)in city or country? (b)time spent in each?
Attending school principally. Leisure spent mostly out of doors. I attended public school 5.5 hours a day.
9- Diseases in your family? From father or mother's side? Nervous Disorders? Rheumatism? Consumption? Dyspepsia? Varicose Veins? Heart Disease? Hernia? Habitual Constipation? Catarrh?
I think there are no diseases in our family which [carry?] through heredity, [unless?] it be a nervous tendency, but this has never developed into a particular disease. There is a very little consumption on both sides.
10- General health before marriage? (b)Since marriage? Good before and since. Paralysis? Brain Fever? Chronic Headache? Nervous Prostation? Catarrh? Hernia? Dyspepsia? Habitual Constipation? Inflammation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose Veins?