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 In corresponding, if the following questions are answered it will give us a very good idea of your condition and will better enable us to judge what will be suitable for you in the way of an artificial limb. Give the number as it appears before the question and then the answer to the question.

1. Your name

2. Post office

3. County

4. State

5. Age

6. Weight

7. Height

8. Occupation

9. Leg or arm amputated

10. When amputated

11. Right or left

12. Above or below elbow or knee

13. If above, give length from body

14. If below, give length from knee pan or elbow joint

15. What is condition of stump

16. Can you take any pressure on end of stump

17. Cause of amputation

18. Ever use an artificial limb

19. If so, what style and make, and how long

20. Was it satisfactory

21. If not, why

22. Have you one of our new catalogues

23. Would it be an inducement for you to give us an order if we sent a man to take your measurements

24. If we did so, would you stand a part of the expense

25. Do you wish to work for a free artificial limb premium? If so, we will send you particulars

Is there any special information you would like on the subject of artificial limbs? If so, let us know what it is, and we will do the best we can to enlighten you.

Date