If "yes," ask who the disabled persons are and mark an X in the box [under the column for that person] corresponding to each response.
Question 21. Is any member of your family blind, dumb, deaf, or do they have any physical impediments or other deficiencies?
[] 2 No
If you have marked the box corresponding to Yes, ask who?, and in the column pertaining to each affected person, make an X in the box or boxes corresponding to the situation, or specify the situation under other. If you marked the box corresponding to no, continue with the next person.
[A depiction of question 21 to the right of the preceding text is omitted here.]
[P. 54]
Keep in mind the following definitions:
Blind: Without the ability to see. Example: unable to recognize written words, colors, persons, or objects.
Deaf: Without sensibility in the ear or the ability to hear.
Dumb: Unable to speak
Paralytic: Without the capacity to move one or various body parts.
Other: This category includes mental deficiency, that is to say, a person who has alterations in their mental functioning, memory, comprehension, capacity to learn, or ability to calculate. Example: Down syndrome, mental retardation, demented, etc.
[A drawing of men with some disability is omitted here.]