Name/Title
Questionnaire, Doctors Office, For WomenEntry/Object ID
2020.1.89WScope and Content
Questionnaire for Women for Doctor B. Frank Scholl from the Library of Health,
Questionnaire reads;
Symptom Blank for Women 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, height, are you married for single, if married how long, have you children, age of youngest, have you had miscarriages, are you memes (or monthly periods) regular, is the discharge more then natural, is it less then natural, are you very sick at these periods, how long do they continue, if very sick, where is the pain located, have you leucorrhoea or whites, if so how long, is the discharge thick or thin, is discharge offensive, is womb painful or tender, is womb lower down then natural, have you dragging sensation or bearing down pain, soreness over the womb or outside, have you weakness or soreness in back, pain or irritation in bladder or vigina, is there burning or smarting after urinating, do you have to rise in the night to pass water, is there a deposit on standing, have you had any private disease or blood disease, if so describe it, are you full of blood or thin and pale, where do you have the most pain, have you any sores, ulcers or tumors, is your general health good, are you weak or debilitated, are you troubled with rushes of blood to the head with dizziness, are you subject to headaches, is your stomach weak and digestion bad, does the wind or gas gather in the stomach or bowels, are your bowels constipated, if so how often do they move, are you subject to despondency and gloomy feelings, what nervous symptoms have you,
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
10-7/8 inLength
7-1/8 in