Form 70
Health Department, City of Haverhill, Mass.
INFANT WELFARE SERVICE.
Ward
No.
Street
House
Floo
1-2-3-B
NAME.
Occupation
Place Mother's Birth.
Place Father's Birth
Occupation
Children: Ahve... . Ages
Youngest Child Sex
... Dead
General Condition
Ages at Death....
Second Child Sex
General Condition
.... Abortions..
Feeding Youngest
Breast....
Breast and
Coma
Cow's Milk only
Pat. Fd...
.Cow's
and.
Feeding Next Youngest:
..Cond. Millk
Water
If the Mother is Nursing what does she take to make milk?
Feeding: Regular.
...... Too often
Night
,How many ?
Feedings
Milk: Boiled
Pasteurized...
Covered...
.
.
Kept on Ice
In Water.
Tub.
Bathing: Sponge
How otten
Too little . . .
Clothing: Too much
Stool: Color..
Consistency..
Bood
No. in 24 Hours.
Mucous
Sickness in House. Cases Diarrhea
Tuberculosis...
Chronic Cough...
..Communicable.
Skin
LIVING ROOMS
SURROUNDINGS
ALLOW
Accumulations
Cleanliness
15
15
ALLOW
Within 50 feet
Garbage-Rubbish
Deduct when Unclean Floors 4,
Walis 3. Ceilings 3, Ledges 3
Windows 2
Yard and Areas
Ventilation
10
15
Adjustable Windows 6, No.
Odor 4.
Space available
Lighting
Deduct 2 Points for every 3
of Floor Space
10
Plumbing on Premises:
Deduct when Leaking 4,
Clogged 4. Odor 2.
10
per cent.
an
of Flies
15
40
Plus Living Rooms
60
Crowding
Rooms, No.
Men Women.
Boarders....
10
100
Final Score
60
[OVER]
