CASE NO.
YEAR
NAME
DATE
WARD
MARITAL STATE
NATIONALITY
AGE
OCCUPATION
REFERRED BY
SEX
COLOR
Single-Married--Widowed
White-Black
Years
Male-Female
ADDRESS STREET
CARE OF
NUMBER
FLOOR
F. B. N. S. E. W.
NUMBER FAMILIES
THE HOUSE:
NUMBER OF STORIES
MATERIAL
BUILT
Brick-Frame
C-B-1-2-3-4-5-6-7
Ten.-A.-P. H.-H.-F. R.-B. H.-L. H.
GENERAL CONDITION OF BUILDING:
CLEANLINESS:
Good-Fair -Bad
Good-Fair-Bad
THE HOMEr
TOTAL AIR SPACE
DISTANCE TO PARK
LIGHT
DARK
DIM
Blocks
Number of Rooms
Number
Number
Number
Cubic Feet
SHOULD FAMILY MOVE
Yes-No
CLEANLINESS:
SINK IN ROOMS:
ROOF AVAILABLE:
Good-Fair -Bad
Yes-No
Yes-No
RECOMMEND
THE FAMILY
WHO CARES FOR PATIENT?
ADULTS
CHILDREN
BOARDERS
Total Number
AGE
FAMILY CLEANLINES
FORM
OTHER CASES IN FAMILY
Neat-Careless-Dirty
HOW LONG IN APARTMENT?
PREVIOUS ADDRESS
RECOMMEND:
ECONOMIC CONDITIONS:
RENT
INSURANCE
NUMBER TO BE SUPPORTED
CHURCH
Month
Week
Name
INCOME PER WEEK
AID
and
Wife
Father
Total Income
Patient
Mother
Others
Sick Benefit
Charitable Sqciety
Church
Employer
Relatives
EARNINGS
OCCUPATION
RECOMMEND
VISITED BY
INSPECTOR
DEPARTMENT OF HEALTH CITY OF MILWAUKEE TUBERCULOSIS FORM 3 T. B.
OVER
