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