BOARD OF HEALTH.
CITY OF CAMBRIDGE
DISEASE:.
Address
Name of Patient
When first taken sick
When first kept in bed.
First day of rash
Age..
Occupation..
Sex
Where?
Any other employment during past three weeks?..
Health before attack:
How long has patient lived here?..
Has the patient (to his knowledge) come in contact with any case of this disease within three weeks?.
Where?. .
When?..
.
Has the patient taken any of his meals elsewhere during the past three weeks?
When?
.. Where?.. .
living elsewhere within three weeks?
Where?.. ..
Has the patient been out of town or
When ?..
..
(QUESTIONS TO BE ASKED AT HIS PLACE OF EATING.)
purchased, without further cooking?
Source of food eaten as
Source of Fish (oysters, lobsters, etc.)
Drinking Water
bIce.. ..
Butter
e
f Buttermilk
do
Vegetables and Fruits
Milk, regular
gCheese
C
..
.
Bakery Products
do
Cream.
extra
d Cool Drinks
do
Ice Cream
Meats
.Bologna
Name of Physician
.Corned Beef.
Confectionery
do
Date filled out
