AN AUSTRALIAN STUDY OF AMERICAN FORESTRY. 17 
1.—GENERAL IDENTIFICATION AND History. 
Name ttre sees Telephone Nowe ence wie 
Address, local: . . 
Nationality : Extraction : 
Date of birth :—Month Day. Year Age 
Under 21 years, give name and address of father : 
Single or married tosses How many dependent on you for support ?............... 
Names of relatives, if any, employed in Forest Service 
Who shall be notified in case of accident ? Name 
Address : 
2.—PHYSICAL CONDITION, 
Have you any of the following disabilities ? (Answer “ yes’ or “no” to each 
inquiry. In case the answer is “ yes,” describe fully, using separate sheet if necessary, 
heading it “‘In re: 2.—Physical Condition ”’) : 
Sore eyes or any defects of vision ? 
Do you wear glasses 2 osc For what reason ? 
Any defect.of hearing ? 
Any defect of speech ? 
Any injury, deformity, or defect of hand, arm, foot, or leg ? 
Tuberculosis in any. form ? 
Asthma or shortness of breath ? 
Any chest, lung, throat, mouth, or nasal disease ? 
Rheumatism ? 
Paralysis ? f 
Rupture ? 
Any bladder or kidney di ? 
Any disease or infirmity not referred to herein ? 
Are you subject to: 
Headache (severe), protracted, or frequent 2... cee 
Convulsions or fits ? re pth Reena Aee Accra 
Nervous exhaustion ? 
Palpitation or any disease of the heart ? 
Stomach trouble ? 
Any symptoms of disease or disability not referred to herein ? 
Describe fully here all disabilities, defects, or infirmities which you now have or 
may have had in the past : 
