FORM 14. APPLICATION for treatment. 
Persons may, in consulting us, make use of the following list of questions, filing out such of them as apply 
to their condition. Address: 
WORLD'S DISPENSARY MEDICAL ASSOCIATION, Buffalo, N. Y. 
^A^Our London Address is 3 New Oxford Street. 
I.I8T OF IMPORTANT QUESTIONS. 
1. What is your name i 
2. What is the name of your Post Office? 
3. What County? 4. State? 
5. Where is your nearest Express Office? ... 
I 
6. What County is it in? 7. State? 
8. What is your age? 9. Sex? 
10. What is your present and former weight? 11. Height? 
12. Complexion? 13. What is your occupation? . 
14. Is it necessary for you to labor hard? 15. Are you married? 
16. Do you use tobacco or snuff? 17. Do you use stimulating drinks? 
18. From what do you suffer most? 
19. How did you lose your health? 
20. Do your bowels move daily? ■ ■■ 
21. Are your appetite and digestion good?.... 
22. Do you experience a sense of weight or fullness in your stomach? 
23. Are you troubled with heartburn or sour stomach? 
24. Are you losing or gaining flesh? 25. Have you piles or anal fistula? 
26. What name have doctors given your disease? 
27. Do you have Catarrh? • 
28. Is there obstruction of the nasal passages? 
29. Does the discharge fall into the throat? 30. Is it profuse or scanty, watery and acrid, or thick and tenacious? 
31. Is it mattery, bloody, crusty, putrid, or offensive? 
32. Are the air passages dry and irritable? 
33. Is the voice or hearing affected? 
34. Do you have frequent spells of sneezing? 35. Is the throat sore?. 
36. Is there tightness or constriction of the throat? 
37. Is your mouth tender and sore? 
38. Do you have palpitation of the heart ? 
39. Have you had diphtheria? 
40. Have you had pneumonia or inflammation of the lungs? 
41. Have you ever bled from the lungs, when and how much? 
42. Have you ever had any scrofulous sores on any part of your body? 
43. Have you ever had any private disease? 
44. What form and when? 
45. Are you troubled with asthma or hay fever? 
46. Do you have severe paroxysms? 
47. How long do they generaly last? 
48. Do they occur in the night or the day? 
49. At what season of the year are you the worst? . 
50. Do you have pain in the back or chest? 
51. Do you gasp or struggle for breath? 
52. Have your grand parents, parents, brothers, or sisters, suffered from asthma or hay fever? 
53. Is your chest full, fiat, or deformed ? 
54. Does jarring your chest hurt or cause you to cough? 
55. Does your breath get short on exertion? 
56. Have you taken medicine for your complaints, what kinds, and how long? 57. How often does your pulse beat in a minute? 
58. How many pints of urine do you pass in 24 hours? 
59. Have you a cough? , 
60. At what time in the twenty-four hours is it worst? 
61. Can you lie on either side without coughing? 
62. Do you expectorate or raise much? 
63. What is its color? 64. Is it thick or thin? 
65. Does it float or sink in water? 
66. Does it contain specks or lumps of gray matter ? 
67. Is it streaked or mixed with blood? 
68. Is it frothy, or tough and sticky and difficult to remove from the mouth ? 
69. Have any of your family or relatives died of consumption? 
70. Are you short of breath? 
71. Have you chills, fever, or night-sweats? 
72. Are your feet and ankles swollen or bloated? 
73. Are you confined to the house? 
74. Have you impaired your constitution by excessive sexual indulgence? 
75. Are you subject to involuntary seminal losses? 
76. How often do they occur? 
77. If a woman, are you troubled with leucorrhea or whites? 
78. Is there a bearing-downing or dragging sensation and tenderness in region of womb? 
79. Is the menstrual function regular? 
80. If suppressed did it stop suddenly or gradually, and when? 
81. Is menstruation profuse or scanty; premature or delayed; clotted or fluid; pale, natural, or dark; easy or painful ? 
82. How many children have you had? Character of last confinement? 
83. Can you come here if necessary, either for examination or treatment? 
84. Have you ever written us about your disease? If so, when? General Remarks. 
If, for want of sufficient space, full answers to questions have not been given, and you think you could do better in this way, 
please describe your symptoms in your own words.