Ze Check age at death of any relatives if you know it. Circle if death was caused by and accident (e.g. automobile or plane crash) cc tit x= co tu —- ee iJ ae oc tr — Co eC Oo <C HE = “v) ~ ee ti ‘) ~ oc iit ox iit F & FF re Oo co = LL Of tit = re Fe bw rt 2 = FF = te Ww WY — “Ww _ es “wy Ww — a Las — oc Lij c bad ox tu Lrg x k =x i) ee F FEF OC D> Zz - rT SF Co <= = �� —_~ tL - = - F bet ox oOo <x vw ti co ox © <r Qo 7) Ww iJ Ww} 2D So oO. i) ee Under 30 ee eee 30 - 40 ee ee 40 - 50 ee ee 50 - 65 ee ee Over 65 ee PRESENT COMPLAINTS 1. Please mark below the chief health problems which you may have now. Try to mark only most important 2or 3. the rest of this questionnaire. Eyes Fars Nose Throat or mouth Heart Circulation Others will be covered in Kidneys, urine, bladder Glands (thyroid or other) Sex organs Overweight or underweight Fever Headaches Blood pressure or stroke Lungs and breathing Allergy (hay fever, hives, asthma) Stomach and swallowing Gall bladder, liver, jaundice Sex problems Cancer Disease of the blood Intestines and bowels Muscle or joints Back (spine and neck) Skin trouble Brain or head Nerves or nervousness Swollen glands Hernia (rupture) Neuritises (sciatic or other) Tiredness-- Loss of pep or energy Pain Other medical problems not listed: