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161
Name Address
Date of birth of admission of first visit.
Milk recommended by Dr supplied by Guardians' Order?
Health of childwhen first taking milk
Disease? Sickness? Diarrhœa?
Wholly breast-fed for partly for
Artificially fed for partly for
Artificial food used How given
Reason for giving up breast-feeding
Was it given up by Doctor's orders?
Nurse child? legitimate?
Occupation of father of mother
No. of rooms occupied by family persons over 12 under 12
Are the parents clean? child properly clothed?
Are directions followed ?
Reason for giving up milk
Date „ „
Subsequent
Visits.
Health.
Remarks.
Weighing.
Date.
Place.
Weight.