Some of the following conditions were asked about earlier, but tell me whether or not -- ever had any of these conditions even if they have been mentioned before.
If "Yes," enter condition and number in Item 1, Section J.
Did -- ever have --?
2. Yellow jaundice?
3. Any other liver trouble?**
5. Any other bowel trouble?**
6. An ulcer?
7. A hernia or rupture?
8. Any other condition of the digestive system? **
10. Hay fever or allergies?
11. Tonsillitis or enlargement of the tonsils or adenoids?*
14. Any other respiratory, lung or pulmonary condition?**
15. Arthritis of any kind or rheumatism?
16. Curvature of the spine?
18. Any other condition affecting the bone, cartilage, muscle or tendon?**
19. Eczema or psoriasis (so-rye-uh-sis)?
20. Trouble with acne?
21. Any kind of skin allergy?
22. Any other kind of skin trouble?**
23. Repeated ear infections?
24. Deafness in one or both ears?
25. Any other trouble hearing with one or both ears?**
26. Blindness in one or both eyes?
28. Any other trouble seeing with one or both eyes even when wearing glasses?**
29. A cleft palate or harelip?
30. Stammering or stuttering?
31. Any other speech defect?**
32. Autism or has -- ever been autistic?
33. Palsy or cerebral palsy?
34. Paralysis of any kind?
35. Mental retardation?
37. Repeated convulsions, seizures, or blackouts?
39. Frequent or severe headaches?
41. Chorea (ko-ree-uh) or St. Vitus' dance?
43. Urinary tract infection?
44. Any other kidney trouble?**
46. Goiter or other thyroid trouble?
47. Cystic fibrosis?
48. Anemia or sickle cell anemia?
49. A heart murmur?
50. Cancer or any kind?
51. High blood pressure?
52. Rheumatic fever?
53. Rheumatic heart disease?
54. Congenital heart disease?
55. Any other heart trouble?**
56. Does -- now have - a missing finger, hand, or arm, toe, foot, or leg?
57. Permanent stiffness or any deformity in the back, foot, or leg? (Permanent stiffness - joints will not move at all)
58. Permanent stiffness or any deformity of the fingers, hands or arm?
59. Did -- ever have any other health problem which lasted for at least 3 months which you have not mentioned?
If "Yes," ask: What was the condition?
1. Item number ____
____ Name of condition
For allergy ask:
2. How does this allergy affect --?
For impairment or ulcer, ask:
3. What part of the body is affected by (Condition)?
Show the following detail:
Head (skull, scalp, face)
Back, spine, vertebrae (upper, middle, lower)
Side (left or right)
Ear (inner or outer; left, right, or both)
Eye (left, right, or both)
Arm (shoulder, upper, elbow, lower, or wrist; left, right or both)
Hand (entire hand, or fingers only; left, right, or both)
Leg (hip, upper, knee, lower, or ankle; left, right, or both)
Foot (entire foot, arch, or toes only; left, right, or both)