Created by gpt-4o-2024-11-20 on 2025-06-08

The image is of a blank medical form used in a free dispensary opened in August 1912. It is intended for patient documentation and includes various fields for recording personal, family, and health information. Here's a breakdown of what it contains:

Header:

• Text at the top reads: "Used in free Dispensary opened in August 1912."

Sections and Fields:

1. General Information:

   • Name
   • Age
   • Address
   • Date
   • Occupation
   • Birthplace
   • Diagnosis

2. Personal History:

   • Weight (present)
   • Weight loss (how much)
   • Conditions listed:
     • Scarlet Fever
     • Scrofula
     • Influenza
     • Bronchitis
     • Bone Disease
     • Pneumonia
     • Fistula
     • Gastrointestinal Disease
     • Tobacco, Cigars, Cigarettes, or Liquors

3. Family History:

   • A blank space to record family medical background.

4. Present Illness:

   • Fields to describe:
     • Cough (character and time)
     • Sputum
     • Hemorrhage
     • Fever
     • Chills
     • Sweats
     • Pain
     • Hoarseness
     • Diarrhea
     • Catamenia (painful or scanty menstruation)
     • Absence (cause unspecified)
     • Temperature (during illness)
     • Malaise

Design:

• Plain, black text on a light-colored card or paper.
• Structured layout with blank spaces for handwritten input next to each field.
• Organized into separate sections to facilitate detailed documentation of a patient's medical history and condition.

This form reflects a systematic approach to medical record-keeping in the early 20th century.

Created by gpt-4o-2024-08-06 on 2025-06-08

The image appears to be a medical form or template that would have been used in a free dispensary opened in August 1912. The form is laid out to capture various details about a patient and their medical condition. It is divided into several sections, each headed by a specific category:

1. Top Section: General Information

   • It is meant to record the patient's Name, Age, Address, Date, Occupation, Birthplace, and Diagnosis.

2. Personal History:

   • This section aims to record information about the patient's weight (present), loss (and how much), and previous medical conditions like Scarlet Fever, Scrofula, Influenza, Bronchitis, Bone Disease, Pneumonia, Fistula, and Gastrointestinal Disease.
   • It also includes lifestyle questions regarding the use of Tobacco, Cigars, Cigarettes, or Liquors.

3. Family History:

   • This section likely captures information related to illnesses or conditions that may run in the patient's family.

4. Present Illness:

   • To be filled with details about the patient's current illness, including specifics like Cough: character and time, Sputum, Hemorrhage, Fever, Chills, Sweats, Pain, Hoarseness, Diarrhea, Catamenia (menstruation) and its characteristics (e.g., painful), Scanty, Absence, Temperature during illness, and Malaise.

The form is designed to organize important medical and personal information to assist healthcare providers in diagnosing and treating patients at the dispensary.

Created by anthropic.claude-3-haiku-20240307-v1:0 on 2025-06-12

The image appears to be a medical record or form used in a free dispensary that opened in August 1912. The form contains various fields to record a patient's personal information, medical history, and current symptoms. The fields include the patient's name, age, address, occupation, birthplace, diagnosis, personal history, family history, and present illness. The form covers a range of medical conditions and symptoms, such as scarlet fever, influenza, bronchitis, bone disease, pneumonia, gastrointestinal disease, and more. The form seems to be designed to gather comprehensive medical information about the patient.

Created by us.anthropic.claude-3-5-sonnet-20241022-v2:0 on 2025-06-12

This appears to be a historical medical form or patient intake document from August 1912. It's a blank medical record form used in a free dispensary. The form includes various fields to collect patient information such as:

• Basic personal information (name, age, address, date)
• Occupation and birthplace
• Diagnosis
• Personal medical history including weight and conditions like scarlet fever
• Various health conditions including scrofula, influenza, bronchitis, bone disease, and pneumonia
• Questions about tobacco, cigars, cigarettes, and liquor use
• Family history
• Present illness details including cough characteristics
• Symptoms such as hemorrhage, fever, chills, sweats, and pain
• Other conditions like hoarseness, diarrhea, and malaise
• Temperature readings

The form is printed on what appears to be aged paper with a yellowed or sepia tone, typical of documents from that era. It's laid out in a structured format with clear sections and lines for recording information.

Created by us.meta.llama3-2-11b-instruct-v1:0 on 2025-05-27

The image presents a vintage medical form, likely from the early 20th century, with a beige background and black text. The form is titled "Used in free Dispensary opened in August 1912." It features a series of questions and spaces for patients to provide information about their personal history, family history, and current illness.

• Name
  • Age
  • Address
  • Date
• Occupation
  • Birthplace
  • Diagnosis
• Personal History
  • Weight, present
  • Loss
  • How much
  • Scarlet Fever
• Scrofula
  • Influenza
  • Brouchitis
  • Bone Disease
  • Pneumonia
• Fistula
  • Gastrointestinal Disease
  • Tobacco, Cigars, Cigarettes or Liquors
• Family History
• Present Illness
  • Cough: character and time
  • Sputum
  • Hemorrhage
  • Fever
  • Chills
  • Sweats
  • Pain
  • Hoarseness
  • Diarrhea
  • Catemenia; painful
  • Scantily
  • Absence
  • Temperature during
  • Malaise

The form provides a comprehensive overview of the patient's medical history, including their occupation, personal history, family history, and current illness. The questions cover various aspects of the patient's health, such as their weight, loss, diagnosis, and symptoms. The form also includes spaces for the patient's name, age, address, and date, as well as a section for the doctor's signature and notes. Overall, the form appears to be a standard medical record used by doctors to document patient information and track their progress over time.

Created by us.meta.llama3-2-90b-instruct-v1:0 on 2025-05-27

This image presents a medical form titled "Used in free Dispensary opened in August 1912." The form is divided into two sections: the top section contains fields for personal information, including name, age, address, date, occupation, birthplace, and diagnosis. The bottom section is dedicated to medical history, with fields for personal history, family history, and present illness.

The form appears to be a historical document, likely used in a medical setting to record patient information and medical histories. The use of a free dispensary suggests that the form may have been used in a charitable or public health context. Overall, the image provides a glimpse into the medical practices and record-keeping methods of the early 20th century.

Created by amazon.nova-lite-v1:0 on 2025-05-27

The image shows a medical form titled "Used in free Dispensary opened in August 1912." The form contains various sections with headings and corresponding details. The headings include "NAME," "Age," "Address," "Date," "Occupation," "Birthplace," "Diagnosis," "PERSONAL HISTORY," "FAMILY HISTORY," and "PRESENT ILLNESS." Under "PERSONAL HISTORY," there are entries for "Weight, present," "Loss," "How much," "Scarlet Fever," "Scrofula," "Influenza," "Bronchitis," "Bone Disease," "Pneumonia," "Fistula," "Gastrointestinal Disease," "Tobacco, Cigars, Cigarettes or Liquors," "Hemorrhage," "Fever," "Chills," "Sweat," "Pain," "Hoarseness," "Diarrhea," "Catarnia; painful," "Scantly," "Absence," "Temperature during," and "Malise."

Created by amazon.nova-pro-v1:0 on 2025-05-27

The image shows a medical form with a header that reads "Used in free Dispensary opened in August 1912." The form is divided into several sections, each containing various fields and labels. The sections include "NAME," "Age," "Address," "Date," "Occupation," "Birthplace," "Diagnosis," "PERSONAL HISTORY," "FAMILY HISTORY," and "PRESENT ILLNESS." Within each section, there are specific fields for recording information such as weight, loss, scarlet fever, scrofula, influenza, bronchitis, bone disease, pneumonia, fistula, gastrointestinal disease, tobacco, cigars, cigarettes, liquors, cough, character, time, sputum, hemorrhage, fever, chills, sweats, pain, hoarseness, diarrhea, catemeneia, painful, scanty, absence, temperature during, and malaise. The form appears to be a comprehensive medical record or intake form used in a dispensary or healthcare setting.

Created by gemini-2.0-flash on 2025-04-30

Here's a description of the image:

The image shows a form titled "Used in free Dispensary opened in August 1912." It is a patient information form, likely used for collecting medical history and symptoms. The form includes fields for:

• Name, Age, Address, Date
• Occupation, Birthplace, Diagnosis
• Personal History: Weight (present), Loss, How Much, Scarlet Fever
• Lists of diseases to check off: Scrofula, Influenza, Bronchitis, Bone Disease, Pneumonia, Fistula, Gastrointestinal Disease
• Tobacco, Cigars, Cigarettes or Liquors
• Family History
• Present Illness: Cough (character and time), Sputum
• Hemorrhage, Fever, Chills, Sweats, Pain
• Hoarseness, Diarrhea, Catemenia (painful), Scantly
• Absence, Temperature During, Malaise

The form consists of lines for filling out the information. The font is a simple, straightforward style. The overall impression is that of a standard medical record form from the early 20th century.

Created by gemini-2.0-flash-lite on 2025-04-30

The image is a form used by a free dispensary opened in August 1912. The form is divided into multiple sections to record patient information. The first section requests the patient's name, age, address, and the date. Next are categories for occupation, birthplace, and diagnosis. The "Personal History" section includes weight, loss, how much, and scarlet fever. Other sections include medical history, and information regarding present illness. The form also features a space for "family history".

Created by us.mistral.pixtral-large-2502-v1:0 on 2025-06-04

The image shows a historical medical form titled "Used in free Dispensary opened in August 1912." The form is designed to collect detailed medical information from patients. Here is a breakdown of the form:

1. Header Information:

   • Title: Used in free Dispensary opened in August 1912.

2. Patient Information:

   • Name
   • Age
   • Address
   • Date

3. Background Information:

   • Occupation
   • Birthplace
   • Diagnosis

4. Personal History:

   • Weight, present
   • Loss (presumably weight loss)
   • How much (amount of weight loss)
   • Scarlet Fever
   • Scrofula (a form of tuberculosis affecting the lymph nodes)
   • Influenza
   • Bronchitis
   • Bone Disease
   • Pneumonia
   • Fistula (an abnormal connection between two body parts)
   • Gastrointestinal Disease
   • Tobacco, Cigars, Cigarettes or Liquors (usage)

5. Family History:

   • This section is left blank, presumably for the patient to fill in relevant family medical history.

6. Present Illness:

   • Cough: character and time
   • Sputum (phlegm or mucus)
   • Hemorrhage
   • Fever
   • Chills
   • Sweats
   • Pain
   • Hoarseness
   • Diarrhea
   • Catemia; painful (presumably referring to painful urination or some related condition)
   • Scantily (possibly referring to the amount of urine)
   • Absence
   • Temperature during
   • Malaise (general feeling of discomfort or illness)

This form appears to be a comprehensive medical questionnaire used to gather detailed health information from patients visiting the free dispensary in 1912. It covers a wide range of health-related questions to help diagnose and treat patients effectively.