 |
Page 1: |
|
| 1 | APPENDIX B.
|
|
| 2 |
FORMS.
XVI.
|
|
| 3 |
Commonwealth of Massachusetts.
REGISTER OF THE BLIND.
|
|
| 4 |
| NAME | Age Group | Blindness Degree | Case No. |
| Color | Conjugal Condition | Name of Spouse |
| Year of Birth | Birthplace | How long in U.S. | How long in Mass. |
| LIVES | Date | With | Address | City or Town |
| REFERENCES | Nearest Relatives, | Last Employer, | Physician, | Church |
| Eye and Ear Infirmary | Service of | Vol. | Page | Date |
| HEALTH | Good | Fair | Infirm | Remarks |
| BLINDNESS Right Eye Left Eye Partial Total | Congenital | Result of disease, viz. | Result of Accident, viz. | Age at occurrence |
| EDUCATION | Special Study or Trade | When |
| Before Blindness | Common | High | Special |
| Since Blindness | School for the Blind | Other Training |
| SUPPORT | Wholly | Partially | Average Weekly Earnings Employed Last 12 Months | Years Employed |
| Occupation | Before Blindness | Since Blindness |
| Family | Income | Pension |
| RELIEF | Name | Date | Public Inst. | Outdoor Relief | Private Inst | Private Societies |
| Referred by | Name | Address | Date |
|
|
| 5 |
XVII.
NOTES FOR SPECIAL INQUIRY CONCERNING BLIND PERSONS OF SCHOOL AGE.
|
|
| 6 |
I. Additional Points of Inquiry.
|
|
| 7 |
1. Blindness: --
Degree, i.e., whether the person is --
(1) Totally blind, or sees light only.
(2) Has sufficient eight to avoid running into objects, sees shadows, etc.
(3) Able to distinguish color and could see to play cards, but can-not see to read.
(4) Can see to read, but cannot use sight long enough for that purpose, i.e., defective sight not helpable by glasses.
Any other cases of blindness in family? Relationship? Chances of improvement in sight?
|
|
| 8 |
2. Mental condition: --
Good, fair or defective?
Note: --
(1) Walk and gait. At what ago did child learn to walk?
(2) Ability to use hands.
(3) Speech. At what ago did he learn to talk?
(4) Personal habits.
(5) Power of voluntary attention.
(6) Ability to show interest connectedly.
(7) Can he be taught?
Attending physician.
|
|
| 9 |
3. Physical condition: --
General appearance.
Any physical defects, as hearing, throat and nose, skin, digestion and nerves? Congenital or not?
Age at occurrence? Physician?
|
|
| 10 |
4. Character and disposition: --
How does the child spend a day?
|
|
| 11 |
5. Family (first name, age, nationality, occupation, earnings, health, habits): --
Father.
Mother.
Brothers.
Sisters.
Number of brothers and sisters who have died? Of what diseases?
Consanguinity of parents?
Circumstances at time of child's birth?
Church.
|
