3. How long have you been acquainted with her?

4. Have you attended her professionally?

5. For what complaint?

6. Is she intelligent and of active habits?

7. General health?

8. Has she flat feet, hammer-toe, or any other defect?

9. Is her vision good in each eye?

10. Is her hearing perfect?

11. Has she sound teeth, and if not, have they been properly
attended to by a Dentist lately?

12. Has she shown any tendency to Rheumatism, Anaemia,
Tuberculosis, or other illness?

13. When?

14. What?

15. Has she ever had influenza?

16. Does she suffer from headaches?