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46
In case of survival, Visit at the end of seventh month, to ascertain the
history of feeding, if not removed.
Date of Inquiry Name of Inquirer
Date of Birth
Extract Place of Birth
from Name and Sex of Suckling
Registrar's\ Name and Surname of Father
Return. I Name and Maiden Surname of Mother
1 Rank or Profession of father
Occupation of Mother
Whether working away from home and where
Date of ceasing and resuming work away from home
Health of Mother
Habits of Mother
Health of Father
Habits of Father
Health condition of Suckling ; or age, cause, and place of death
State mode of feeding in special detail
Breast Milk alone, from to
,, supplemented by Cow's Milk from to
Cow's Milk alone, from to
„ supplemented by other foods from to
Has Condensed Milk been used, partially or alone, for what period, and
what brand
If fed by bottle, the kind used, and from when to when
Number of children borne by mother
Number of children alive
Ages and causes of deaths of children
Ages and condition of living children
Cleanliness of family and dwelling
Lighting and aeration of dwelling
Number of sleeping and living rooms in dwelling
Number of persons under and over 10 years of age in dwelling
Situation of dwelling in house
Class of house
This inquiry, according to the circumstances of each case, is extended to the
sanitary inspection of the whole of the dwelling-house premises, to the
inspection of the workplace (if any) of the mother, and to the milk and other
food supplies, and the places whence they are derived.
General hygienic information is given to the mother, and great stress is laid
upon the importance of maintaining the health of the mother during the
expectant and suckling period, and in the case of any derangement, and above
all before weaning, to seek medical advice.
The following leaflet as to obtaining "Medical Advice" is provided for the
guidance of the Women Inspectors, voluntary Lady Visitors, and other
advisors of expectant or suckling mothers: —