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Blank no.3 3.
14.What do you believe to be the purpose of intercourse? Reproduction, and a physical communing, which is an outward token of the spiritual and intellectual marriage.
Necessity to the man? Not a necessity, but next door to it. to the woman? Not at all.
b) Pleasure? Yes aside from the physical aspect.
c) reproduction? Yes.
15. Have you ever used any means to prevent conception? if so, a) what? b) What was the effect on your health? Several times during first months of marriage, took a soap and water injection, but with no effect on health that I am aware of. Since then have used nothing.
16. What would be to an ideal habit? About twice a month.
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Blank No. 3 Series II Form B. 1.
Date Feb. 15. 1893.
Your Father: 1 - Nationality, if American, of what descent? English descent.
2 - Home in city or country before marriage? Country.
3 - Home in city or country after marriage? City.
4 - Age when married? 24
5 - Occupations before your birth: Teaching.
b) after your birth? Real estate.
6 - Health previous to your birth? Excellent.
b) After your birth? Good, aside from chronic asthma
7 - Number of children living, a) boys? b) girls Two.
8 - Number of children dead; give age at time of death and cause.
a) boys. b) girls. One son. Aged 26, consumption.
9 - If your father is living, give his age and present health, if dead, age at death and cause? 68 - Fairly good, aside from asthma.
10 - Name any diseases in his family. Asthma, rheumatism.
Your Paternal Grandfather: home in city or country?
1 - Age when married?
2 - Occupations?
3 - Health?
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Blank No. 3 Series II. Form B. 2.
(continued) 4 - Number of children? 8 number reaching maturity? 7
Your Paternal Grandmother: home in city or country?
1 - age when married? 18
2 - occupations? Care of house.
3 - health? Good.
4 - Age and cause of death? 80 - Weakness of old age. paralysis.
Your Mother: 1 - Nationality, if American of what descent? English.
2 - home in city or country before marriage? Country.
b) home in city or country after marriage? City.
3 - Occupations before her marriage? Teaching.
b) after her marriage? Housekeeping Family Cares.
4 - Note any prenatal influences before your birth.
5 - her health previous to your birth? Fairly good.
b - after your birth? As good as could be expected when constantly overworked.
6 - Number of miscarriages? One.
7 - Her age if living and present health? if not, age at time of death and cause? 56. Consumption:
8 - how was your mother's health affected by the climacteric (change of life).
9 - name any diseases in her family. Consumption.
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Blank No. 3 Series II. Form B. 3.
V - Your Maternal Grandfather: home in city or country? Country.
1 - age when married? 28
2 - occupations? Drayman. Farmer.
3 - health? Good.
4 - number of children? 10 b) number reaching maturity? 6
VI - Your maternal grandmother: home in city or country? Country.
1 - age when married?
2 - occupations? Care of family.
3 - health? Good.
4 - age and cause of death? 48. Immediate cause. Measles with cold which caused quick consumption.
VII - Your husband: nationality, if American, of what descent? English.
1 - date of birth? 1864
2 - early life in city or country? Country
3 - height? 5 feet - 10 3/4 inches.
4 - weight? 160
5 - muscular or weak? muscular.
6 - Where educated? degrees if any? Cornell. C.E.
7 - If a college man has he been athletic? Not especially
8 - Complexion? Dark.
9 - Temperament?
10 - doe he use tobacco? Not habitually
11 - occupations? Teaching.
12 - health? Excellent.
13 dieseases in his family: nervous disorders? Rheumatism? consumption? Dyspepsia? Varicose veins? Heart Disease? Hernia? Habitual Constipation? Catarrh?
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Blank No. 3 Series II. Form B.
Yourself: 1 - date of birth? 1863
2 - Early life in city or country? City.
3 - height? 5 feet 7 3/4 inches.
4 - weight? 130.
5 - complexion? Medium.
6 temperament?
7 - Where educated, give dregrees if any? Cowell B.S.
8 - Occupations before marriage? a) in city or country? b) time spent in each? Teaching in Normal School in Town. (b) Four years.
9 - dieseases in your family? from father or mother's side? Nervous Disorders? Rheumatism? Consumption? Dyspepsia? Varicose Veins? Heart Disease? Hernia? Habitual Constipation? Catarrh? Consumption on mother's side; also [???]. Asthma on father's side.
10 - General health before marriage? b) Since marriage? Paralysis? Brain Fever? Chronic Headache? Nervous Prostation? Catarrh? Hernia? Dispepsia? Habitual Constipation? Inflammation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose veins? (a.) Excellent. (b) First two years - not good, since then fair.
