Hygiene and Physiology of Women Volume X: Sex Survey

Blank No. 5 5 Form B.

Date. April 1892

1.Age when married?. Twenty five

2. General health a) before marriage excellent B) after marriage excellent

3. what knowledge of sexual physiology had you before marriage? Knowledge of plant reproduction and casual observation of animals.

4.Number of times married? If more than once additional blanks will be furnished you to answer the following questions in regard to each marriage. Once.

5.Number of years married? nearly two. ([??] June '90)

6.Do you habitually sleep with your husband? No.

7.Number of conceptions? One

8.Number of children? State in connection with each, date of birth, sex, whether healthy or not; Note any characteristic and the cause if you can give it Daughter born June 25, 1891. Very strong per haps due to god care in pre-natal condition.

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ank No. 5 2.

9. Did conception occur by choice or by accident? Indifferent - though not deliberate choice

10. Habit of intercourse? Average number of times per week? About once or twice per month? per year? Note - First occurance - nearly a month after marriage.

11. Was intercourse held during pregnancy? a) If so, a) how often? occasionally b) did you desire it during this period?

12.At other times have you any desire for intercourse? not initiative a) how often? b) At what times in relatino to your menses? earlier more prom inent.

13.Is intercourse agreeable to you or not? Yes - not necessary Do you have a venereal orgasm? " 1. When you do, a)effect immediately aftewards? b) effect the next day? Note - Early morning

2) When you do not, a) effect immediately afterward b) effect the next day?

*Continence a few days before menstrual period and at least eleven days after

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Blank No. 5 3

14. What do you believe to be the purpose of intercourse? Reproduction a) Necessity To the man? Perhaps To the woman? No b) Pleasure? Secondary - though to be re cognized from mental & physical point of view.

15. Have you ever used any means to prevent conception? If so a) what? b) What was the effect on your health? a - Syringe - tepid water. b - no apparent effect.

16.What to you would be an ideal habit? Never formulated. Satisfied with present circum stances.

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Blank No. 5 Series II. Form B. 1

Date

Your Father: 1 - Nationality, if American, of what descent? Am. from Eng.

2 - Home in city or country before marriage? New country wh. grew into village.

3 - Home in city or country after marriage? " " " "

4 - Age when married? 31

5 - Occupations before your birth? Most everything except manual labor.

b) after your birth? Banking.

6 - Health previous to you birth? Comparatively good, but always delicate.

b) - after your birth? Same.

7 - Number of children living: a) boys? one b) girls one.

8 - Number of children dead; give age at time of death and cause. a) boys. 0 b) girls. 0

Second child, 4 1/2 younger than brother.

9 - If your father is living, give his age and present health, if dead, age at death and cause? about 69, feeble, but [???]

10 - Name any diseases in his famly. Grandfather had asthma Catarrah [trouble?]

Your Paternal Grandfather: home in city or country?

1 - Age when married?

2 - Occupations? - Small farm as remembered

3 - Health? feeble but lived over 80 Consumptive

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Blank No. 5 Series II Form B. 2.

(continued) 4 - Number of children? 8 number reaching maturity?

Your Paternal Grandmother: home in city or country?

1 - age when married?

2 - Occupations?

3 - health? Very good

4 - Age and cause of death? 87. one stroke of paralysis.

Your Mother: 1 - Nationality, if American of what descent? Dutch descent

2 - home in city or country before marriage? then moved into town 2 or 3000 people

b) home in city or country after mattiage? "

3 - Occupations before her marriage? taught school for a year

b) after her marriage? housewife

4 - Note any prenatal infuences before your birth. Mother much annoyed by [??] of [??] & [??] after in hot summers.

5 - her health previous to your birth? very good

6 - after your birth? very good

6 - Number of miscarriages?

7 - Her age if living and present health? if not, age at time [deleted]of death and cause[deleted] 62 nervous trouble, eyes droop at 50 very [??]

8 - how was your mother's health affected by the climacteric (change of life). present condition may be due to it but was not sick as many women are

-75- 9 - name any diseases in her family. one member had cancer[?] taken from his lip.