What is the nature of your ailment?…………………………..
………………………………………………………….
How long so affected?……………………………………….
Ever taken Silent Treatment?…………………………………
Ever had a severe accident, shock, great sorrow or disappointment?
Please give particulars.
………………………………………………………….
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Are you subject to moods; high tempered; erratic?………………
Are you reading Dr. Bush's books?…………………………….
Which ones?………………………………………………..