Name/Title
Questionnaire, Doctors Office, For MenEntry/Object ID
2020.1.89UScope and Content
Questionnaire for Men for Doctor B. Frank Scholl from the Library of Health,
Questionnaire reads;
Symptom Blank for Men Date ____19
All letters free from observation. Any further symptoms can be written on back. Enclose two cent stamp and address. B. Frank Scholl, M.D. 1420 N. Seventeenth St., Phila., Pa.
Questions, Answers
Age, Weight, married or single, condition of your general health, occupation, from what do you suffer most, cause, if known, condition of urine, condition of bladder, do you suffer with backache, have you difficulty passing urine, is urine scanty or high colored, do you have to get up at night to pass urine, how often, have you gas in the stomach or bowels, are your bowels constipated, is your memory bad, inclined to be despondent, have you ever had any private or venereal or blood disease, state full particulars, have you been cured, have you varicocele or stricture, do you use liquor to excess, do you suffer from nervous debility or lack of power, have you ever had a chance of syphilis, have you been treated for it.
Write plainly Name__ Address__ Read carefully and follow instructions below. Always mail all symptoms Blanks and correspondence to B. Frank Scholl, M.D. 1420 North Seventeenth Street, Philadelphia, Pa.
Group of documents found in a box that belonged to Captain Charles Nelson and Family.Lexicon
Nomenclature 4.0
Nomenclature Primary Object Term
QuestionnaireNomenclature Sub-Class
Other DocumentsNomenclature Class
Documentary ObjectsNomenclature Category
Category 08: Communication ObjectsDimensions
Height
10-1/4 inLength
7-1/8 in