_Name and Surname_ ______________________________ _Age_ ________
_Name of Parents_ ________ _Mother's Age_ ___ _Father's Age_ ___
_Professions_ __________________________________________
_Details of Hereditary Antecedents_ ____________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
_Personal Antecedents_ ________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
+-------------------------------------------------------------+ | Standing | Weight | Chest | Seated | Index of | Ponderal | | Stature | | Meas. | Stature | Stature[8] | Index[9] | |----------+--------+-------+---------+------------+----------| | | | | | | | |----------+--------+-------+---------+------------+----------| | | | | | | | +----------+--------+-------+---------+------------+----------+
+------------------------------------+ | HEAD | |----------------+-------------------| | | Dia. | Dia. | Cephalic | | Cir. | Front | Across | Index | | | to Back | | | |------+---------+--------+----------| | | | | | |------+---------+--------+----------| | | | | | +------+---------+--------+----------+
_Physical Constitution_ ________________________________ _Condition of Muscles_ ________________________________ _Colour of Skin_ ______________________________________ _Colour of Hair_ ______________________________________
NOTES _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
[8] For the Index of Stature Dr. Montessori combines the seated and standing statures.
[9] The Ponderal Index is found by combining the height and weight.
As will be seen, these charts are very simple. I made them so because I wished the doctor and the schoolmistress to be able to use them freely and independently.