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J.
F. Has the applicant ever had any of the diseases
F no
of the digestive system If yes, describe.
1
Inquire particularly regarding appendicitis.
3
VI. The Genito-Urinary System.
VI.
an
1030 aced
T
A. The specific gravity and reaction of the urine?
A
B. Is any albumen present, by heat and acid, or
B
no
by Heller's test ? Both tests required.
C. Is any sugar present by Fehling's tests or by
C
no
fermentation?
D
no
D. Results of microscopic analysis, if necessary.
E no
E. Is there any derangment of the bladder?
2
F. Of the kidneys?
F
no
a
5
VII. The Cutaneous System.
VII.
Has there ever been or is there any disease or
no
functional derangement of the system?
VX.
V.X
10 secoaib
VIII. The Organs of Sense.
VIII.
IV2 A no
.VVX
A. The sight. Does the condition of the eyes in-
dicate that they should be examined by a
avods
adt
ni
3110
specialist?
B. The hearing. Any discharge from ears?
B no
C. Other senses.
C. no
IX. Have there been any cases among the parents,
IX.
brothers or sisters of the applicant of :
A. Consumption?
A
no
B. Insanity ?
B.
Teo
C. Is there any predisposition hereditary or ac-
C.
quired, to gout, rheumatism, cancer, arterial
disease, diabetes, or nervous disorders, es-
pecially headaches, insomnia, nervous ex-
haustion, chorea or epilepsy If yes, state
no
nature.
X. A. If the applicant is a woman, is she now suf-
X. A
fering or has she ever suffered from uterine
or menstrual disorder. (It is desirable that
Reg painless
3
particular attention be given to this inquiry
as the climate overseas bears heavily on those
4
thus affected.)
6
&
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"ocrText": "J.\nF. Has the applicant ever had any of the diseases\nF no\nof the digestive system If yes, describe.\n1\nInquire particularly regarding appendicitis.\n3\nVI. The Genito-Urinary System.\nVI.\nan\n1030 aced\nT\nA. The specific gravity and reaction of the urine?\nA\nB. Is any albumen present, by heat and acid, or\nB\nno\nby Heller's test ? Both tests required.\nC. Is any sugar present by Fehling's tests or by\nC\nno\nfermentation?\nD\nno\nD. Results of microscopic analysis, if necessary.\nE no\nE. Is there any derangment of the bladder?\n2\nF. Of the kidneys?\nF\nno\na\n5\nVII. The Cutaneous System.\nVII.\nHas there ever been or is there any disease or\nno\nfunctional derangement of the system?\nVX.\nV.X\n10 secoaib\nVIII. The Organs of Sense.\nVIII.\nIV2 A no\n.VVX\nA. The sight. Does the condition of the eyes in-\ndicate that they should be examined by a\navods\nadt\nni\n3110\nspecialist?\nB. The hearing. Any discharge from ears?\nB no\nC. Other senses.\nC. no\nIX. Have there been any cases among the parents,\nIX.\nbrothers or sisters of the applicant of :\nA. Consumption?\nA\nno\nB. Insanity ?\nB.\nTeo\nC. Is there any predisposition hereditary or ac-\nC.\nquired, to gout, rheumatism, cancer, arterial\ndisease, diabetes, or nervous disorders, es-\npecially headaches, insomnia, nervous ex-\nhaustion, chorea or epilepsy If yes, state\nno\nnature.\nX. A. If the applicant is a woman, is she now suf-\nX. A\nfering or has she ever suffered from uterine\nor menstrual disorder. (It is desirable that\nReg painless\n3\nparticular attention be given to this inquiry\nas the climate overseas bears heavily on those\n4\nthus affected.)\n6\n&"
}