14. Are there indications in the heart’s action of organic, muscular, or nervous derangement?
If so, describe fully.
15. Are there indications that the applicant is addicted to the excessive use of intoxicating beverages, tobacco, or narcotics in any form.
If so, describe fully.
16. Has the applicant any form of disease or disability which is likely to unfit him for the performance of the work of the position for which he applies?
17. State whether the applicant is capable of prolonged, severe, mental and physical exertion, and equal to the demands of a very exhausting occupation.
18. Are you a regularly licensed physician, and duly authorized by the laws of your State to practice medicine?
19. Of what medical institution are you a graduate?
This space is to be filled out by the applicant in his own handwriting, in the presence of the physician.