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earliest convenience whether yon desire a supply of the Forms to
be sent to you, and if so, what number you expect to require.
He hopes that the present circular, taken together with the
previous circulars, sufficiently deals with the various points which
the inquiry involves, but he need hardly add that he will be very
happy to afford any Medical Officer of Health any further explanation
required, and to advise at any time with regard to any
difficulties which may arise in the course of the inquiry.
I am,
Sir,
Your obedient Servant,
HERBERT SAMUEL.
The following form for use in the enquiry was drawn up by a
special Committee appointed at the Conference at the Home Office
on November 6th:—
No. of Case Date of first Visit
Sanitary District Date of last Visit
Mother. Name
Address
Age Race and Nationality
Living with Husband. Living apart. Widowed. Unmarried.
General Health. Good. Indifferent. Bad.
Character of Confinement
Doctor. Midwife Institution.
Previous History. No. of Miscarriages Still Births
Children born alive Now living Died in 1st year of life
Description of work before present pregnancy
Other information
Note.—In cases where the woman has
been engaged only in domestic
duties at home, either before or
after childbirth, "Nil' should
be written across the part inapplicable.
Work during pregnancy. How long ceased before birth
Precise occupation
Carried on at home. In factory or workshop. Elsewhere.
Weekly earnings Nature of work. Heavy. Light.
Special conditions
Work after birth. Resumed weeks after birth.
Why resumed
Precise occupation
Carried on at home In factory or workshop Elsewhere.
Weekly earnings Nature of work. Heavy. Light.
Special conditions