ABORTIVE
TYPE SPINAL
CEREBRAL
POLIOMYELITIS
Name
Age
Sex
School.
Residence
Floor
Private House.
Apartment.
Nationality
Occupation
When Vaccinated.
Any Sick or Paralyzed Animals
Adults
How Many Children in Family
Flies
Sanitary Conditions.
Are Windows Screened.
Is Patient Isolated Properly
Previous Health of Patient.
G. F.
P.
Any Illness or Accident within a Month (Patient or Other Member of Family).
Patient Out of Town within a Month
Nature of IIlness.
Any Association with a Case of Polio. (Patient or Member of F.)
Where
Tonsils N. E. When Removed
If So, Name, Address and Date.
Date of Paralysis
Date of Onset of Present IIlness
Hand
Neck
Back
Thigh
Distribution of Paralysis at Worst.-Face.
Shoulder.
Arm.
Forearm.
Leg
Foot.
Headache. Vomiting. Pain.
Sore Throat. Tenderness
Retraction of Neck
General Symptoms.-Fever.
Restlessness. Drowsiness. Unconscious.
Death
Results.-Recovery (No Paralysis). Improved.
Date
Remarks
