...................................................................

How long so affected?..............................................

Ever taken Silent Treatment?.......................................

Ever had a severe accident, shock, great sorrow or disappointment?
Please give particulars.

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...................................................................

Are you subject to moods; high tempered; erratic?..................

Are you reading Dr. Bush's books?..................................

Which ones?........................................................

Are you willing to earnestly work in harmony with the treatment when

sent out?........................................................

Name...............................................................

Address, Street and No.............................................

...................................................................

City.................................State.........................