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30
Patient Isolated in Bedroom In Living Room No Isolation
Separate Attendant Other duties of Attendant
Previous health of Patient—Good Fair Bad
Previous illnesses of Patient How long resident in house
Recent visits to other Houses
Suspected source of infection
Previous Cases of Diphtheria in the same house in vicinity
Nature of other recent cases of illness in the House
Special Points to be noted
Date of Inspection
Age M. F. Occupation. Place of Work, or School. *Diphtheria History. Date of Onset. Last at Work or School.
*A.—Have had Diphtheria B.—Have not had Diphtheria. C.—Now ill.