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Blank No.[42?] Series II. Form B. 4.
[VIII.?] Yourself: 1. Date of birth? May 13, 1862
2- Early life in city or country? Up to ten years country of Iowa then small city, then S.F. Oakland Berkeley, till marriage.
3- Height? 5ft 4 inches
4- Weight? about 125 pounds
5- Complexion? Medium fair
6- Temperament? Ardent
7- Where educated, give degree if any? Univ. California B.L.
8- Occupations before marriage? a)in the city or country? b)time spent in each?
Married at twenty, just out of college

9-Diseases in your family? From father or mother's side? Nervous disorders? Rheumatism? Consumption? Dyspepsia? Varicose Veins? Heart Disease? Hernia? Habitual Constipation? Catarrh? None of these. Father died of cancer.

10- General health before marriage? (b)Since marriage? Good. 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? Rhuematism? Pneumonia? Jaundice? Varicose Veins?
Have been sick only once in my life. Had typhoid fever in my sophomore year in college. It caused constipation which persisted for fifteen years, and was cured by physical exercises.