Yes
Gonorrhea or Syphilis... .
Anemia. .« 2. « s © © © © we we
Jaundice. . . 2. ee sw we we
Epilepsy. ...
ran
Migraine headaches. cee ee
Tuberculosis. . . 6 « s «6 6
Valley Fever. . 2... 2 eee
Diabetes. . 2... ee ew we
Cancer. . 2. 2. 2 ee ee es
High blood pressure or low blood pressure .......
Parasites, worms, amoeba. ....
°
Cy
Nervous breakdown .....-
Food, chemical or drug poisoning.
Hay fever or asthma .....
Hives or eczema ....
.
Frequent infections or boils.
Frequent colds or sore throats.
Any other disease ......
ALLERGIES:
Penicillin or sulfa.....
Aspirin, codeine or morphine.
Mycing or other antihiatics
Mertniolate or Mercurochrome.
Any otner drug. .......
Any foods... . 2... 2a
Adhesive tape. .......
Nail polish or other cosmetics.
Tetanus antitoxin or serums .
INJURIES:
Broken or cracked bones...
Sprains . 1. 2. 6 we ew ee ee
Lacerations .. 1... «eee
Dislocations ......e-.
Concussion or head injury .
Have you ever been knocked unconscious? cs ee ee
*
+
TRANSFUSIONS:
Blood or plasma transfusion .
SURGERY :
Tonsillectomy ... 1... ee ee
Cancer or malignant tumor... .,
Non-cancerous disease ....
Removal or loss of a finger,
*
toe,
No
Unknown