Document zb0Xmn3pV4KaY3pOyaL6oM997

/Federal Register / Vol. 51, No-119 / Friday.June 20,1966 Rules and Regulations , UA. Do'you consider yourself to oe in good health? ' . Yeb Ho it- NO. 'state, reason .. . 13B. In'tne "past year, have you ' developed: Yee No Epilepsy?. . J_ Rheumatic fever?. - Kidney disease? . Bladder, disease? . . Diabetes?- ___ __ . . . * Jaundice?. _ Cancer?. - - ___ ' H.` CHEST COLDS AND CHEST ILLNESSES ` 14A. It you'get a- cold. does it usually go to-your chest? '. (Usually- neans more than 1/2 the.tine) - y\ 1. Yes 2.' No _ , . V. 3. Don't get colds~ ISA. During tne past year., have you had. any chest illnesses.that have kept you' ott work, indoors at bone, or in.bed?' l. Yec.^____ 2. No _ 3. Does Not Apply Z If.YES TO ISA: 1SB; Did you prodace phlegm with any ota these chest 'll.lneceec? tsc. tn the past year, how many such illnesses with (increased) phlegn did you have which lasted a week' or more? l.. Yes _ 2. No __ 3. Does Not. Apply Number of illnesses _ No such- illnesses . 16. HKSPJRATORY SYSTEM in. the past year ' have'.you had: Asthma Yes or" No' . further Comment on Positive. ' Answers- bronchitis Hay fever Other Allergies 6ILUM0 CODE 45lO*-C Pneumonia Tuberculosis Choot Suruery Other Lung Problems Heart Oicease Do you have: Fteguem. colds Chronic cough Shortness ol breath when walking oc climbinq one Might or ctairc Do you: wneere Cough up phlegm Smoke cigarettes Yee oc No KUUher Comment on Positive Answers _ -- ________ -- "> : -- ;-- Yec or No -- Further Comment on Positive Answers ______ -- . Packs per day How many years Date signature 22775, GLEASON-001023