Including the items you have marked above, mark below how you
fee] about your general health.
My general health is good.
My general health is fair.
My general health is poor.
My general health interferes
with my work or my way of living.
When was your last visit to the doctor?
Within the past year
Within 2-5 years
Within 1-2 years
More than 5 years ago
Mark the number of days you have been unable to do your ‘usual work
in the past year due to illness (being sick).
ay
3 or less
4-7
BH T4
More than 14
Mark tne number of days you have Deen unable to do your usual work
in the past year cue to an accident cr injury.
Sor lessss
4-7ss
B14
=—s«éMrle than 14
PERSONAL MEDICAL HISTORY
Mark any disease on the list which you have had, and any which caused
complications or permanent damage or continuing trouble.
Measles . . 1. 1 sw sw we he
German Measles. .....«
©
«6
Chicken Pox .
..
+
«
«©
2
«
Smallpox.
ee
a
._
je
@
#@®
oe
Pneumonia . . .
Influenza...
1
1.
1
6
«
6
es
ee
ee ww we
© we ee
ew
wo
Mumps . . . 6 ee ew ew we ew ee a
Whooping Cough. ......
.
Scarlet Fever or Scarletina .....
Diptherja . .. 1. 1 ee we te
Pleurisy.
.
*
¢
e
ee ew
ew we
.
.
e
.
*
¢
ee
et ew es
Rheumatic Fever or heart disease.
Arthritis or Rheumatism . . 1...
.....
ee ew es
Any bone or joint disease . 1... 2 ee ew
Neuritis or Neuralgia... ... 2 ee
Polio or Meningitis ..... 1. 2 2 ee
Malaria 2. 2. we ee we we wt we ee ee
eee
we
eee
es
~
Bright's disease. . 2... ee we te ew wwe