142 MASS. EXPERIMENT STATION BULLETIN 241 



Serial No. HOME RECORD 



Surname Address Date... 



1927 



L Pre-School History 



A. Mother's Diet in Pregnancy 



1. Milk, anit. da. 



2. Potatoes x da. 



3. Other veg. x da. 



4. Leafy veg. x wk. 



5. Fruit, cooked x da. 



6. R. fr., veg., c. torn, x wk. 



7. Bread, wh. gr. x da. 



8. Cereals, wh. gr. x wk. 



9. Eggs X wk. 

 10. Meat X da. 



B. Infant Diet 



1. Breast fed, mos. 



2. Fresh milk, began, mo. 



3. Raw, past., began, mo. 



4. Milk modifier or subst. 

 Kind, began, mo. 



5. Other foods: 



a. Potatoes x da. 



b. Other veg. x da. 



c. Orange juice 



d. Bread or cereal, 

 ref. or wh. gr. x da. 



e. Eggs X wk. 



f. Cod liver oil 



