Confidential
The Foreign Mission Committee of the Presbyterian Church in Canada
89 Confederation Life Building, Toronto

Questions to be answered by the Medical Examiner.

1. Name and residence of applicant, and how long a resident of present locality?
2. Have you had previous acquaintance with the applicant?
3. State weight, height and figure of applicant.
4. What is the temperament of the individual- nervous, lymphatic or bilious?
5. Does general appearance indicate vigorous health, medium health or want of vigor?
6. Does a thorough examination of the chest, indicate any disease of heart or lungs?
(a) If there are any abnormal sounds, please refer to them at length, and state your opinion as to their significance?
(b) Is the true respiratory or vesicular murmur complete?
(c) What is the number of respirations in a minute?
(d) What is the number of pulse beats in a minute, and what is the condition of the artery as to tension? (If any marked deviation from normal condition exists, please examine another day).
(e) What is the amount of chest expansion (in inches)?
7. Is the applicant subject to cough, hoarseness, loss of voice, difficulty of breathing, palpitation of the heart?
8. Are the functions in a healthy state, of
(a) The brain and nervous system?
(b) The muscular system?
(c) The digestive system? How is the appetite affected by heat, nervous strain, or loss of sleep?
(d) The urinary organs? If unhealthy, please state particulars.
8. [sic] Have the parents, brothers, or sisters of applicant been affected with pulmonary or other diseases hereditary in their nature? If so, state what.
10. Has any injurious effect been produced upon the constitution by previous illness, injury or surgical operation?
(a) Has the applicant ever had malarial fever, and if so, does there now exist any appreciable result of this disease? State particulars.
(b) Is the applicant specially sensitive to the heat of the sun in the summer?
(c) Does the applicant perspire freely?
11. Does there exist any predisposition to local or constitutional disease?
12. State, as far as you know, what was the age at death, cause of death, and duration of final illness of each of the following persons, if deceased. What is the age and present state of health of each of them, if now living? If you do not know, please inquire and report.

Father, Mother, brothers, sisters:
Age, if living- State of Health- Age at Death- Cause of Death

13. Do you consider the state of health such as would render the applicant an acceptable risk to any first class life insurance company?
14. Is there any defect of eyesight or hearing; if so, what?
15. Has the applicant been successfully vaccinated or not? It so, when last?
16. Are there any facts known to you affecting the health of the applicant not brought out by the above questions? If so, please state them. Please refer in detail to any abnormal condition that may be known to you.
17. Is the constitution of the applicant in your judgement adapted to the climate of [blank]

Dated at [blank] 1906
Attest:
Name of Medical Examiner.
To be signed by Medical Examiner and forwarded, with bill, to

Rev. R.P. Mackay, B.A., D.D.
Secretary Foreign Mission Committee.
Presbyterian Church in Canada. Toronto.

N.B.- It is expected that the Medical Examiner will make such other enquires as he may think proper, and that the examination will be thorough, exact, and circumstantial, that he will feel the responsibility of his office, bearing in mind that upon his statements great reliance will be placed by the missionary applicant and his friends, and by the Board.