Document 5bBgdzgLJYyBZNzoeXwk08er5

/Federal Register V oI/S ii.N o. 119 / Friday. June 20.1966 / Rules and Regulations 0. Are you suffering froa or beve-;you ever'suffered firoa: a. -Spilepsy (orAfite,, seizures, convulsions)? 1--j: b. Bbeueatic fever? Ci * c. Kidney disease? Ci-- d. Bladder disease? Ci' e. Diabetes? f. jaundice? -" Ci Cl ; CHEST COLDS AMP CHEST _U,i.NES3HS i3 Ci Ci , Ci Ci., . t-_i ; It you get a cold, does it 'usually so. to your 1. `.-Yes 2. NO chest?. (Usually means sore than 1/2 the'tioe) ' ). Don \t get .colds 20A. During tne pest 3 years, neve you bad-airy chest 1. -Tes illnesses-tbat have kept you off work-, indoors at boae. or. in bed? 2.;No Ilf YES TO 20A:. ' B. Did you prodbce-.phlega with any of these cbest . 1. 'Yes.__ . -2. -9IO illnesses? ' 3.. Does Not: Apply C. In the last 3 years, bow many speb Illnesses- . Kuaber- of Illnesses with, (increased)-'pblega did.you have which' No such .illoesseo '. lasted a week or.aore7 21. Did you nave any lung trouble before the age of 1-.-Yes' 2.'no. 16? 22. Have-you ever bad any of tbe following?: lAi Attacks of bronchitic?; ` V. Yes __ 2. No ik yes to iA: B/ Was it conf irmed by a doctor? ' 1'-. Yes - - 2. No 3; Does Not.Apply C. At what ag's was your f irst'attack? ' v :;Age rin-;Yeare.-' Does Not.Apply;.' - 2A.- Kneunonia (include bronchopneoaenia)? ; ' l. .rep ; .'2. Wo- IK TBS - TO 2A: .' B. Was it confirmed by a doctor?. i ' ' '* ^ 1. Yes ^ 2.-.,No 3 :/Does-Not Apply C. At what aoe did you first have it? / .A^e-in.Years: Does Not-> Apply 3A. Hay Fever? IK YBS TO 3A: B. Has it confirmed by a doctor? .. 1. Yes ^ 2. No __ 1.. Yes- Z ' 2.' No __ 3.. DoesT?ot- Apply' C. At vnat age did it start? ; vAge-in .Years. __ Does Not Apply _ 23A.'Have you ever had chronic bronchitis? 1. Yes __ 2. No IK YBS TO 23A: B. .Do you still have it? 1. Yes __ . 2. No _ '3.. Does Not Apply. __ C. Mas it confiraed by a doctor? 1. Y8 Z 2. No _ .3.. Does Not Apply. __ D. At what age did it start? - Age In Yeat6 Does Not Apply 24A. Have you ever bad eapbyseaa? 1. Yes, __ - 2. No __ ... IK YBS TO 24A: B. Do you etill have it? . 1.. Yes _ '. 2. No'i_ 3. Does-Not Apply ^ C. Has it confiraed by a doetor? . 1. Yes _ 2. No _ 3. Does Wot Apply ' D. At what age did it start? - Age in Years ` Does Hot Apply __ 2SA. Have you ever had S6tbaa? l. Yes __ 2. No__ IK YBS TO 25A: B. Do you Still have it? 1. Yes __ 2. No ' 3. Doss Not Apply. __ C. Has it confirmed by a dpetor? 1. Yes __ 2. No________ 3. Doss Not Apply . . ,D. At what ags/.did it start?. Age in Years '. ~ DOSS Not Apply ^i B.-If you no longer have it. at what age did it stop? 26. Have you ever bad A. Any other chest illness? -Age stopped .__ : Does Not Apply __ 1. Yes _ 2. No __ If yes. please specify 22771 GLEASON-001019