(40) Ever desired to wear apparel of psychical sex..... Ever worn such apparel since childhood......... ........................................................................
(41) If a physical male, fondness for loud or fancy apparel..... If female, for plain apparel.............. ........................................................................
(42) Ever arrested or imprisoned for following instincts of psychical sex..... If so, aggregate number of months or years imprisoned..............................................
(43) Please note any other significant data as to particular homosexualist on separate sheets.
GENERAL QUERIES:
(44) Approximate number of homosexualists—positively known as such—have you encountered in your life-time: Passive inverts.... Active pederasts.... Male psychical hermaphrodites.... Physically female homosexualists....
(45) How many additional individuals have been under your suspicion: Passive inverts.... Active pederasts.... Male psychical hermaphrodites.... Physically female homosexualists....
(46) The author of “Autobiography of an Androgyne” estimates, roughly, passive inverts as 1 out of 300 physical males. Please give your estimate: Passive inverts, 1 out of....males. Active pederasts, 1 out of....males. Male psychical hermaphrodites, 1 out of....males. Female psychical hermaphrodites, 1 out of....females. Other physically female homosexualists, 1 out of....females. (In query 46, only adults are to be considered.)
NAME AND ADDRESS OF PHYSICIAN SUBMITTING SCHEDULE. THIS INFORMATION WILL BE CONSIDERED CONFIDENTIAL, AND IS ESSENTIAL.
Name......................