TUBERCULOSIS.
History Blank No
Name
Age
Single Married Widowed Divorced
Residence.
Private House Boarding House Hotel Tenement Apartment
Working
Where
Occupation.
Nationality
If foreign born how long in the United States.
Type of disease.
Duration.
Stage.
Result of sputum examination
Sanitary condition of home
Are all reasonable precautions being taken to prevent spread of disease to others.
By
Reported.
Medical Attendant.
Aided by-
Change of Residence.
From
Date
To
When Disinfected
HEALTH DEPARTMENT,
Springfield Mass
Termination of case.
