Daniel Lewis, M . D 
Commissioner 
New York 
STATE DEPARTMENT OF HEALTH 
Albany 
Pulmonary Tuberculosis Records 
Collective investigation through Local Boards of Health 
for the purpose of securing a census and allied data of con- 
sumption in the State. 
1. Initials of the sick Age Sex 
2. Residence (town, village or city) 
3. Occupation 
4. Nationality 
5. Duration of the disease 
6. Source of infection 
[Often some origin can be traced or inferred.] 
7. Family history of tuberculosis 
8. Are others of the household affected? 
[Recently or at the present time] 
g. Sanitary surroundings 
10. Tenement house? 
11. Precautions to prevent spread 
12. Attending physician 
Dated 
(Signed) 
Health Officer of 
♦[Additional data may be put on the hack of this. The purpose of securing the initials is to 
obviate duplicate reports of a case, and may be omitted if this is guarded against. It is not pro 
posed hereby to secure a registry of cases of consumption.] 
Form 23 
28363