12 
EESIDEXCE. 
How long resident in District of Columbia, . 
Residence when taken sick, ; from to . 
Pre'vdous residences, ; from to . 
Subsequent residences, ; from to . 
Temporary absences from District of Columbia within thirty days prior, 
Number of occupants ; ages, . 
Number of occupants who have had t>"phoid, ; when, . 
Newcomers in house within three months prior, . 
Newcomers in house had t\*phoid? . 
Serv'ants: 
White: Resident, . T]i,q)hoid? . 
Nonresident, . T\-phoid? . 
Colored: Resident, . Tt,-phoid? . 
Nonresident, . Tt-phoid? . 
T^-phoid at homes of servants? . When? . 
Disposal of sewage, . Water-closet in house? . 
Water-closet in yard? . Pri^w? . Location? . 
General sanitary* condition of residence, . • 
OCCUPATTOX. 
Place, : from to . 
Other cases, . 
WATEE. 
Within thirty days prior, — 
sionally, . 
Within thirty days prior, 
Where taken, . 
Hilk (how used), ; from - 
Ice cream? . Where? . 
Uncooked fruits and vegetables. 
Shellfish, . 
Solely, 
FOOD. 
. Boiled? . 
COXTACT. 
Principally, . Occa- 
Pasteurized? . 
Association thirty days prior with patients in febrile stage, . 
Association with suspected cases, . 
Association with persons who have had tt*phoid within six months, ; one year, 
; two years, ; three years, ; four years, ; five years, . 
Association thirtt* days prior with persons in contact with patients in febrile stage, . 
Treatment of stools and urine of patients, . 
Other precautions, . 
Remarks: . ' 
Summary : . 
Signature : 
