Hygiene and Physiology of Women Volume X: Sex Survey

Blank No. 6 Form A.

[deleted]1. Name in full.[deleted] [deleted]2. Address.[deleted] 3. Date of birth. Jan. 16th 1865 4. Place of birth. Wesel, Germany. 5. Where educated; give degrees if any. Occupations before marriage. Give length of time spent in each. My whole life was one of mental & physical strain. I studied three years in Ripon College and taught five years. 6. Nationality of mother. German. (Grandmother French) 7. Nationality of father. German. 8. age of mother when married. Nineteen. 9. Age of father when married. Thirty-seven. 10. General health of parents. Good. 11. Nationality of husband. American. (father = Spanish - mother - French Hugenot) 12. [deleted]Age of[deleted] [inserted]Date of Birth of[inserted] husband. [deleted]at present time.[deleted] Oct. 16th, 1859.

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Blank No. 6 3

14. What do you believe to be the purpose of intercourse? Reproduction. a) Necessity to the man? no. to the woman? no. b) Pleasure ? no. c) Reproduction? yes. 15. Have you ever used any means to prevent conception? no. If so a) What? -- b) What was the effect on your health? -- 16. What to you would be an ideal habit? Intercourse at desired intervals until pregnancy occurs, then abstinence until end of lactation.

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Blank No. 6 Series II. Form B. 1.

Date April 3d 1893

[2?] - Your Father: 1 - Nationality, if American, of what descent? German. 2 - Home in city or country before marriage? City 3 - Home in city or country after marriage? City. 4 - Age when married? 37. 5 - Occupations before your birth? Oficer in the army. b) After your birth? None 6 - Health previous to your birth? Good. b) After your birth? Excellent. 7 - Number of children living; a) boys? one. b) girls? three. 8 - Number of children dead; give age at time of death and cause. a) boys. --- b) girls. our girl died by acccident at the age of three. The other died from meningitis when over twenty 9 - If your father is living, give his age and present health, if dead, age at death and cause? He died at the age of 92 from old age. 10 - Name any diseases in his family. Asthma.

- Your Paternal Grandfather: home in city or country? City. 1 - Age when married? -- 2 - Occupations? Government oficial. 3 - Health? Good.

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Blank No. 6 Series II. Form B. 2.

I (continued) 4 - Number of children? Three. Number reaching maturity? all

I Your Paternal Grandmother: home in city or country? village.

1 - age when married? --

2 - occupations? --

3 - health? She was an invalid for many years.

4 - age and cause of death? --

2 - Your Mother: 1 - Nationality, if American of what descent? German.

2 - home in city or country before marriage? Village.

b) home in city or country after marriage? City.

3 - Occupations before her marriage? Student.

b) after her marriage? Teacher and student.

4 - Note any prenatal influences before your birth. --

5 - Her health previous to your birth? Good.

b - after your birth? Later in life heart disease developed and she was not very strong

6 - Number of miscarriages? --

7 - Her age if living and present health? 75 if not, age at time of death and cause? Health good.

8 - How was your mother's health affected by the climacteric (change of life). not at all, as far as I know.

9 - name any diseases in her family. Her mother had chronic headache.

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Blank No. 6 Series II. Form B. 3.

[?] - Your Maternal Grandfather: home in city or country? Country (?)

1 - age when married? --

2 - occupations? Student

3 - health? Delicate.

4 - number of children? one. b.) number reaching maturity? one.

[2?] - Your maternal grandmother: home in city or country? Country or village.

1 - age when married? --

2 - occupations? --

3 - health? Fairly good.

4 - age and cause of death? --

III - Your husband: nationality, if American[underlined], of what descent?

1 - date of birth? 1859, Oct 16.

2 - early life in city or country? Country.

3 - height? 5 ft 9 in.

4 - weight? 156 lb.

5 - muscular or weak? Muscular.

6 - Where educated? degrees if any? A. B. Ripon College, Ph.D., J. H. U.

7 - If a college man, has he been athletic? no.

8 - Complexion? dark.

9 - Temperament? Sangine

10 - Does he use tobacco? No, not habitually.

11 - Occupations? Teacher.

12. Health? Excellent.

13 Diseases in his family: nervous disorders?[underlined] Rheumatism? Sporadi[s?]ease Consumption?[underlined] Dyspepsia? Varicose viens? Heart Disease? Hernia? Habitual Constipatio? Catarrh?

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