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64
THE ROYAL BOROUGH OF KENSINGTON.
ACUTE RHEUMATISM ENQUIRY CARD.
Name Address No.
Age years months Sex Date of notification
Dr. Date of onset School attended
Places where patient has lived in last five years (in chronological order)
No. of rooms occupied by family
No. of families in house
Position of rooms: basement, first, second, third floor
Evidence of dampness
Is there a damp course?
Is there any evidence of this being defective?
Is there any dampness in the rooms occupied by the patient's family?
How many feet does the dampness spread up the walls in the rooms occupied by the
patient's family?
Is the dampness present all the year round or in Winter only?
If patient lives in basement, is the floor of wood, concrete or stone?
Is there ventilation under the floor?
Lighting of rooms Good Fair Poor
Ventilation of rooms Good Fair Poor
Cleanliness of rooms Good Fair Poor Verminous
Cleanliness of clothing Good Fair Poor Verminous
Family
Occupation of father Occupation of mother
Brothers—how many? Ages
Sisters—how many? Ages
How many children sleep in the same room as the patient?
Have any persons sleeping in same room shown any signs of rheumatism, chorea,
tonsillitis, growing pains?
No. of children in house not sleeping in same room as the patient?
Have any of these shown any signs of rheumatism, chorea, tonsillitis, growing pains?
Health Record
Other
Father Mother Brothers Sisters Relations
Acute rheumatism
Chorea
Tonsillitis
Growing pains
Tuberculosis
Has the patient had scarlet fever? If so, give date
Have the patient's tonsils been operated on? If so, give date
Has the patient been in hospital for acute rheumatism or been under previous medical
attention for it?
Is the patient confined to bed or able to go out?
Is the patient attending school?
Is the patient receiving regular medical attention now?
Is the doctor willing that patient should attend Rheumatism Supervisory Centre?
If the patient has attended the Rheumatism Supervisory Centre, indicate date of
first attendance
Remarks
Signature
SUBSEQUENT HOME VISITS.
VISITS BY HEALTH VISITOR.
Date Remarks Initials