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I. Give age and cause of death of:

1. Mother's mother
2. Mother's father
3. Father's mother
4. Father's father
5. Father
6. Mother
7. Brothers

8. Sisters II. State any peculiarities or abnormal nervous or mental conditions in

family or ancestors, such as the following: (Answer “Yes”
or “No.")

I. Stammering or stuttering
2. Headaches
3. Dizzy spells ..
4. Fainting spells
5. Despondency or “ blues"
6. Fiery temper
7. St. Vitus's dance
8. Fits
9. Epilepsy
10. Paresis
II. Nervous breakdowns
12. Mental diseases (insane)
13. Feeble-minded (imbeciles)
14. Remarks ..

III. Name diseases in family, including three generations, if possible :

(Answer “Yes” or “No.")

1. Consumption
2. Tuberculosis
3. Bright's disease
4. Diabetes
5. Cancer
6. Scrofula
7. Syphilis
8. Malaria
9. Remarks

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IV. State any special talents or abilities in your family or ancestors :

(Answer “Yes” or “No.")

1. Music

3. Mechanical
4. Executive
5. Professional
6. Remarks

V. Give occupations of:

1. Father
2. Mother
3. Brothers
4. Sisters
5. Grandparents
6. Remarks

VI. Did you have any of the following diseases or conditions? (Kindly

answer by “Yes” or “No.")

1. Measles 2. Mumps 3. Scarlet fever 4. Whooping-cough 5. Chicken-pox 6. Diphtheria 7. Stammering or stuttering 8. Sleeplessness 9. Pneumonia 10. Influenza 11. Typhoid fever 12. Operations 13. Headaches 14. Dizzy spells 15. Fainting spells 16. Coughing spells 17. Fits, convulsions, or spasms 18. St. Vitus's dance 19. Despondency or 20. Fiery temper 21. Fits of anger 22. Nervous breakdown 23. Frequent dreams 24. Nightmare 25. Blushing (frequent) 26. Blind or half-blind for a short time . 27. Deaf or dumb for a time ... 28. Loss of memory 29. Biting of finger-nails 30. Ever see a vision ? ... 31. Ever hear imaginary voices ? 32. Asthma


33. Hay fever
34. Twitching of face muscles
35. Walk in sleep
36. Does your nose more or less constantly itch?
37. Paralyzed ...
38. Wet bed (how old when stopped)
39. Stumble in the dark ....

40. Fear of going insane VII. Kindly answer the following questions by “Yes” or “No” when

possible :

1. Does your hand tremble when you attempt to use it?
2. Are you usually well? ....
3. Do you feel tired and achy in the morning ?
4. Does your head ever ache on one side? ....
5. When your head aches do you see colored lights?
6. Were you happy as a child ? ...
7. Did you often become blue or discouraged between the ages

of 12 to 20 years? ....
8. Do you like to be alone?
9. Do you like to make new acquaintances ?
10. Does the sight of blood make you feel faint or wish to run

away? .....
11. Do you get tired easily? ....
12. Do you seem to think people are watching you on the street

or in public places? .
13. Are you afraid to cross open spaces ?


afraid of crowds or closed places ? 15. Do you belong to a lodge or club? ... 16. Have you held any offices in a lodge, club, or other organiza

17. Has any one "got it in " for you?
18. Anybody persecuting you?
19. Were you always treated right by your family and em-

ployers? .....
20. Are you satisfied with life?
21. Do you think that you are getting a square deal in life?
22. Were your parents

(a) Poor? ....
(b) Moderate means?
(c) Well-to-do?

(d) Wealthy? ...
23. Do you

(a) Own your own home?
(b) Rent home?
(c) Rent flat?
(d) Rent apartment ?
(e) Rent room? ....
(f) Live with parents ?

14. Are

24. Were you raised in

(a) City? ...

(b) Country?
25. What school did you attend?
26. How much schooling have you

27. What grade did you reach?
28. Did you ever fail in school?
29. What grades did you fail in, and how many times in each?..

(Please answer in full.) 30. Name the occupations you have had and length of time

worked at each? .. 31. Were your comrades during childhood and adult life good,

bad, or indifferent? .....
32. What kind of amusements do you like?
33. Have you any special talents? ....
34. How long at your present or last occupation, and what are

or were your wages?
35. Are you anxious for advancement ?
36. Do you like responsibility? ....
37. What special abilities have you?
38. What would you like to do? ...
39. How long have you been in the state?
40. Are you a citizen of the United States ?
41. Have you children?
42. Have you ever been arrested ?

43. Do you laugh or cry easily? ...
It will be noted that the preceding questions include:

I. Family history. .
II. Health history.
III. Personal history.
IV. Social history.

V. Education.
VI. Industrial history.
VII. Reaction toward present environment.
VIII. Special abilities.
IX. Nervous and mental phenomena which would indicate

further examination.


I am indebted to Lieutenant A. Warren Stearns of the neuro psychiatric division of the United States Navy for a compilation of tests which I have found to answer my purpose very well up to the present time. Inasmuch as Steams'” test has been standardized for a number of occupations in the United States Navy, it would be well to utilize it until a more practical one is compiled. However, as the work in industrial examinations proceeds the need for other tests, special trade tests, and tests for special abilities, becomes manifest. These are being developed at present and will be presented at a later date.

The following is Lieutenant A. Warren Stearns' test, which should be known as the “ Stearns'" test:

The score is upon the basis of 100—20 points for each testfive tests in all.

1. Trabue test.
2. Disarranged sentences test.
3. Cancellation test.
4. Auditory memory test.

5. Visual memory test. In industrial examinations it has been found that the No. 2 test is especially valuable in testing ability to quickly recognize relationship of well-defined and easily recognized parts to a given whole (assembling). More difficult tests have been suggested. No. 3 test is good for speed and accuracy and attention.


(Quoted from Dr. Stearns.) In giving the directions for these tests, it is essential that every point be clearly understood by every one who is capable of understanding. This can be assured in no other way than by giving the directions slowly and distinctly, with proper expression and emphasis. Before being given, it should be seen that the test is clearly understood. In order that the meaning of each sentence may be fully grasped, it should be followed by a pause. A good rule is to allow a pause of two seconds after each sentence. The

*Lieutenant A. Warren Stearns kindly gave permission to use his compilation of tests and to publish it. His test, with full instructions and results of his work, will shortly appear in book form. In it he gives credit to all originators of his test.


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