| Sleep: | Bed alone | With another |
| Outdoors | Indoors, scant ventilation | |
| Indoors, windows open | ||
| Regular bedtime hour | Irregular | |
| Quiet before bedtime | Excitement before bedtime | |
| Early | Late hour | |
| Given soothing syrups | ||
| Bathing: | Daily water baths | Less than one daily |
| Number | Too frequent | |
| Kind | Too warm | |
| Temperatures | Not followed by cool | |
| Cool sponge | ||
| Air baths | Not given | |
| Sun baths | Not given | |
| Feeding: | Regular hour | Irregular |
| Prescribed intervals | Intervals too short | |
| ” ” long | ||
| Eating between meals | ||
| Simple diet | Injurious foods | |
| Balanced, rational diet | Dietary not analyzed | |
| ” poorly balanced | ||
| Chews well (2) | ||
| Eats slowly | Rapidly | |
| Motor Activity: | Encouraged | Restricted by clothing |
| ” by carriage | ||
| Outdoors or open-air room | Indoors; poor ventilation | |
| In raised, sanitary pen | On floor | |
| Toys sanitary | Unsanitary; allowed pacifier | |
| ” harmless | Dangerous | |
| Surfeit | ||
| Kept from crowds | Taken to stores (4) | |
| ” ” theater (10) | ||
| ” ” movies (8) | ||
| Handling: | Moderate | Excessive |
| Rational | Lifted by arms | |
| Tossed | ||
| Rocked | ||
| Jolted |
History
| Feeding: | Maternal nursing 9 to 12 months | Less |
| More | ||
| Cow’s milk | Bottle: how long | |
| Patent foods (specify) | ||
| Illnesses: (state age, duration, permanent effects) | Bronchitis | Subject to colds coughs, constipation, indigestion, nervousness, other illness |
| Convulsions | ||
| Diphtheria | ||
| Earache | ||
| Eczema | ||
| Epilepsy | Operations (age) for adenoids, tonsils, vaccination, others | |
| Measles | ||
| Meningitis | ||
| Mumps | ||
| Rheumatism | ||
| Rickets | ||
| Scarlet Fever | ||
| Scurvy | ||
| Summer Complaint | ||
| Tuberculosis | ||
| Whooping cough | ||
| Others |
Heredity
| Mother | Father | |
| Nationality | ||
| Race | ||
| Height | ||
| Weight | ||
| Occupation | ||
| Education |
Predispositions
| Mother’s[31] | Father’s[31] | Brothers | |
| Mother Family | Father Family | or Sisters | |
| (how many) | (how many) | (how many) | |
| Marked mental gifts | |||
| Nervous disorders | |||
| (form) | |||
| Alcoholism | |||
| Tuberculosis | |||
| Kidney disorders | |||
| Cancer | |||
| Pulmonary weakness | |||
| Digestive disorders | |||
| Blindness (form) | |||
| Deafness (form) | |||
| Living | |||
| Dead | |||
| Ages at death | |||
| Causes of deaths |
Congenital Factors
| Rank in birth (1st, 2d, etc.) | |||
| Age of brothers and sisters | Living: | At death: | If had lived: |
| (in years and months): | |||
| Mother | Father | ||
| Age at birth | |||
| Vigorous[32] | |||
| Fair health[32] | |||
| Sickly[2] | |||
| Nervous[2] | |||
| Use alcohol[32] | |||
| Excess | |||
| Moderate | |||
| Use tobacco[32] | |||
| Excess | |||
| Moderate | |||
| Use drugs[32] | |||
| Excess | |||
| Moderate |
Indications