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bcs_75_dhs
Child Health and Education in the Seventies
Under the auspices of the University of Bristol and the National Birthday Trust Fund
Director: Professor Neville R. Butler, MD, FRCP, DCH
Department of Child Health Research Unit University of Bristol
CONFIDENTIAL
DEVELOPMENTAL HISTORY SCHEDULE

Health District Code

Generic text

Child's Local Serial Number

Generic text

Child's Central Survey Number

Generic text

Full Name of the Child

Generic text

Sex

Generic text

Address

Generic text

Date of birth

Date of birth
If moved into present Health Authority/Board since birth, please give:

name of previous A.H.A./L.H.A., or Health Board

Generic text

age (approx. in years and months) of N when moved to present A.H.A./L.H.A./Health Board

Generic text
Notes for Completion of Schedule
1. Aims
The purpose of this Schedule is to obtain data on the utilisation by the study child of child health clinics, health visiting facilities, developmental screening tests and other important aspects of the community health services. As parental recall of past events is often incomplete, reference to pre-school child health records is also essential as a means of confirming and supplementing information obtained by the Health Visitor in the home interview.
2. Person(s) Completing Schedule
Ideally the Health Visitor who is carrying out the home interview should also complete this schedule. Some of the information may require access to records usually held centrally, such as in Area or Distict Offices or in Health Boards (Scotland), e.g. special handicap records, centrally held registers. The personnel used and arrangements made for completion will doubtless be decided by the Area or District officer responsible according to local contingency.
3. Records Required
(a) The following basic types of records are essential for the main part of this schedule.
(i) Records used by health visitor to record health visiting, e.g. Home Visiting records, Consultation Record Cards and, where available, Family Records. These will be referred to as H.V. records,
(ii) Records used in Child Health Clinics or Child Welfare Clinics by doctors to record developmental screening and other health care, e.g. MCW 46. These will be referred to as C.H.C. records.
(b)Some questions require reference to other sources, in addition to the above basic records - for children for whom there may be letters or reports indicating past hospital outpatient attendances or inpatient care, children who are on observation or other registers, children who have been assessed for special educational treatment and other children who have handicaps or disabilites. In some instances, this information will be available in H.V.'s or C.H.C. records, but arrangements will probably be necessary for this to be supplemented from records or information held centrally.
(c) Records about developmental screening are needed for question 4. The majority of general developmental check-ups and specific screening tests will be recorded on records used by doctors in Child Health Clinics and on H.V. records. Additional information about any developmental check-ups at G.P. practices or health centres would be valuable, and may be readily available to health visitors attached to G.P. practices. Developmental check-ups are sometimes carried out elsewhere, e.g. at hospital birth follow-up clinics, and vision and hearing are often screened during routine medical examination at day nursery, nursery and infant school. This information would be appreciated if it is readily available.
4. Developmental Screening & Assessment
Developmental screening in Q.4 refers to check-ups usually routinely performed on all pre-school children to identify those who may be developmentally delayed or have a suspected vision or hearing defect.
Developmental assessment in Q.5 refers to a much more detailed examination of development, which is usually only performed on children who have already been identified as having a possible delay or defect in hearing, vision or other aspect of development.
What to include as Developmental Screening in Q.4 Part I
(a) Any record of a routine general developmental examination or a check-up of overall developmental progress.
This term does not refer to an isolated single screening test, though specific screening tests may often be included in the general observations and examination made of the child's developmental achievements. General developmental examinations or check-ups of overall developmental progress are usually carried out at or near prescribed ages in C.H.C, home or G.P.'s practices by doctor or health visitor. The result is often entered on C.H.C. or H.V. records under several headings of 'developmental' function e.g. hearing and language, posture and locomotion, vision, social behaviour, or may be entered in the form of observations of individual developmental achievements of the child, e.g. sitting, smiling, saying single words, etc. If neither of these forms of recording are present in the notes, but it is definitely indicated that a general developmental check-up was made, this should be included. Please include also any record you may have of a general medical examination or check-up carried out by a doctor at nursery or infant school.
(b)Any record of tests for vision, hearing or squint.
Vision and hearing may be tested on their own or as part of a general developmental examination or check-up of overall developmental progress. They are routine clinical procedures used for testing these special functions, e.g. routine testing of hearing by rattle, paper etc. by H.V. at 7-9 months, screening of vision by Stycar 5-letter test at age 3 years. If the details of the type of test used are not clear but the records indicate that vision, hearing or both have been checked, such entries should be included as vision or hearing tests.
Any record that there has been a check-up for a squint should be entered separately as "examination for squint" and not be entered as a vision test in section b of the table in Q.4. Include as "examination for squint" any occasion where records indicate a specific test was made, e.g. cover test or light reflection test, or where the records indicate only if a squint was, or was not, evident in the course of a general examination. Records of any such test(s) for vision, hearing or squint carried out at nursery or infant school should also be included.
(c) Please exclude from Q.4 Part I any remarks or observations of developmental progress made at times other than the developmental screening examinations and tests described above. Details of these should be entered in Q.4 Part II.
5. General Notes
(a) Every question should be answered.
(b)Please base your answers only on information which is contained in the record form(s), registers etc. There is space provided below each question for you to add any information known to you from other sources.
(c) If you have any difficulty in interpreting or reading the relevant entry on records, ring code marked "records unclear" and give details in the space for "comments" at the end of the question.
(d)If you do not have the relevant record(s) at all when answering a question, please ring code marked "No records".
(e) Allowance should be made for the fact that the format of every question inevitably cannot correspond with all the different recording systems in use throughout the country. Space is therefore provided at the end of each question for comments, and for supplying extra data such as:
(i) additional information known to you but not on the records;
(ii) details of any difficulties with obtaining or interpreting the data on the relevant record;
(iii) other observations, e.g. where the information given on records is considered not to reflect a true picture of the actual events.
(f) Some abbreviations are used in this schedule, e.g.
Study Child ... ... ... ... ... ... N
Health Vistor records ... ... ... ... ... H.V. records
Child Health Clinic records used by doctor ... C.H.C. records
Local Health Authority ... ... ... ... L.H.A.
Area Health Authority ... ... ... ... A.H.A.
Phenylketonuria ... ... ... ... ... P.K.U.
Question ... ... ... ... ... ... Q
(g) Further details about C.H.E.S. and on the completion of questions are given in "Survey Notes and Information".
ALL INFORMATION RECORDED ON THIS SCHEDULE WILL BE TREATED AS STRICTLY CONFIDENTIAL IN ACCORDANCE WITH MEDICAL RESEARCH COUNCIL REGULATIONS AND NO CHILD WILL BE IDENTIFIED OR REFERRED TO IN ANY REPORT BY NAME.

Do the Health Visitor's records or child health clinic records indicate that N has ever had for any reason whatsoever - any home visit from H.V.?

1
Yes
2
No
3
Records unclear
0
No records

Do the Health Visitor's records or child health clinic records indicate that N has ever had for any reason whatsoever - any attendance at C.H.C.?

1
Yes
2
No
3
Records unclear
0
No records
If yes to either of above, please give further details:
qc_1_a == 1 || qc_1_b == 1

Give date of first H.V. visit* and first C.H.C. attendance for any reason whatever. First H.V. home visit*

Generic date

Give date of first H.V. visit* and first C.H.C. attendance for any reason whatever. First C.H.C. attendance

Generic date
Give the total number of visits from H.V. and N's C.H.C. attendances for any reason whatsoever, in each time-period specified below.
Total number of H.V. home visits * Total number of C.H.C. attendances
How manyHow many How manyHow many
First year: Child's age in months 0-5: Time period Apr. 1970 - Sep. 1970
First year: Child's age in months 6-11: Time period Oct. 1970 - Mar. 1971
Second year: Child's age in months 12-17: Time period Apr. 1971 - Sep. 1971
Second year: Child's age in months 18-23: Time period Oct. 1971 - Mar. 1972
Third year: Child's age in months 24-29: Time period Apr. 1972 - Sep. 1972
Third year: Child's age in months 30-35: Time period Oct. 1972 - Mar. 1973
Fourth year: Child's age in months 36-47: Time period Apr. 1973 - Mar. 1974
Fifth year: Child's age in months 48+: Time period Since April 1974
Total since birth
* Exclude any visit where no access gained to home and note such visits in "comments" below.

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text
Please state if H.V. or C.H.C. records indicate that N's history contains any risk factors - either as a complication or condition which occurred during the perinatal period (pregnancy, labour, or postnatal in first week), or as a genetic, social or environmental factor.
Include the following type of entries as risk factors.
(i) Any entry of a condition of N in space specially provided on the H.V. or C.H.C. record form for risk (or similarly named) factors, or any entry of a condition specified on the H.V. or C.H.C. record as reasons for inclusion in at risk/observation register.
(ii) Any condition which, though not directly labelled as a risk-factor in the above records, is implied to be a risk factor by virtue of being printed in a check-list of abnormal conditions on the H.V. or C.H.C. record form. One example of such a list is on the front page of C.H.C. record MCW 46.
Include all above conditions, irrespective of whether N's name was actually placed on a Register or not.

Is there any risk factor recorded: on H.V. records?

1
Yes
2
No
3
Record Unclear
0
No records

Is there any risk factor recorded: on C.H.C. records?

1
Yes
2
No
3
Record Unclear
0
No records
If yes to (a) or (b),
qc_2_a == 1 || qc_2_b == 1
ring any condition(s) listed below which correspond to risk-factor(s) reported in N's records. Ring risk factor(s) reported from H.V. records separately from C.H.C. records. If any risk factor(s) reported in N's records do not correspond exactly or nearly exactly to any condition listed below, ring the category 'other risk factor' and specify the nature of the risk-factor in the space provided.
Pregnancy/Delivery Other risk factor in pregnancy/labour, specify First week of N's life Other risk factor(s) specify Social or Genetic Social or environmental risk factor(s), specify Genetic risk factor(s), specify

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther
H.V. record
C.H.C. record
Where "combined" record used, with both H.V. and C.H.C. doctor's entries, ring both columns and note "combined record" in comments below.

Comments, e.g. Notes unclear, records absent, extra information etc.

Generic text
Please refer to notes 3(c) and 4(a-c) at the beginning of this schedule concerning Q.s 3-4.

Do the records specified below contain any indication that the following have been done? Is there a record of: From H.V. or C.H.C. records only N's birthweight?

1
Yes
2
No
3
Records unclear
4
No Records
If yes,
qc_3_a == 1

specify ... lbs ... oz or ... gm

lbs
oz in pounds
gm

Do the records specified below contain any indication that the following have been done? Is there a record of: From H.V. or C.H.C. records only N's gestational maturity?

1
Yes
2
No
3
Records unclear
4
No Records
If yes,
qc_3_b == 1

specify ... wks

wks

Do the records specified below contain any indication that the following have been done? Is there a record of: From H.V. or C.H.C. records only Any congenital defect in N?

1
Yes
2
No
3
Records unclear
4
No Records
If yes,
qc_3_c == 1

specify specify

Generic text
Do the records specified below contain any indication that the following have been done? Is there a record of:
-
Any screening for P.K.U.?
Any screening for CDH (hip)?
Any screening for hearing?
Any screening for squint?
Any screening for vision?
Any gen. devlp. check-up(s)?
If yes to (f), (g), (h) or (i), please ensure that each test or check-up is entered in Q.4.

Comments, Notes unclear, records absent, extra information, etc.

Generic text
Part I Please complete table below for each occasion N received developmental screening (exclude P.K.U./hip tests) - either a general developmental examination or check-up or a screening test of hearing, vision or squint, (see notes on page 2).
When "screened"? What was done? Ring all that apply Who screened N? Where screened?
Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
Note that only the fact that N was tested is to be entered in the answer to this question; details of any referral for assessment or for further investigations for suspected delay or abnormality should be recorded in Q.5.
Notes for completion of section (b) in table below.
Whenever records indicate that a routine general developmental check-up or examination was made, ring 1. If a hearing test, a vision test and/or an examination for squint was included as part of this general developmental check-up, ring 2, 3 and/or 4 as appropriate. If a comprehensive developmental scale, e.g. Denver or Griffiths, was used, ring 1, 2 and 3 even though individual components may not be specified; please name any such scale used in "comments" below the table. Ring 2, 3 and/or 4 in section (b) if screening for hearing, vision and/or squint was done on occasion(s) separate from a general developmental check-up.
In answering section (c) below, give the main person responsible if more than one person carried out tests or made observations on any one occasion.

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text
Part II Please enter below the details of any observations of developmental progress which have been made at times other than on the occasions of routine developmental screening examinations or tests, described in Part I. If not known by whom or where observed put NOT KNOWN. If more space required, please continue on back page of schedule.
Date Who observed N? H.V. or Dr. Where observed C.H.C./home/G.P.'s etc. Summary of observations recorded
Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text
1
2
3
4
Is there any information on available records, reports or letters that N has ever been seen for assessment (see note 4 on second page) or for further tests, as a result of a (suspected) defect in hearing or vision or any other developmental problem? Include assessments in special assessment/handicap centres as well as hospital OP/IP situation.
-
specialist hearing assessment or further hearing tests
specialist visual assessment or further eye tests
specialist or further assessment for any other developmental problem.*
*e.g. delay in motor, intellectual, mental, language, social or emotional development.
If yes ringed to (a), (b) or (c),
qc_5_a-c == 2 || qc_5_a-c == 3
please give details below for each referral.
Date Problem for which referred, diagnosis if recorded, and any further details Name and address in full of hospital, clinic, or assessment centre
Generic dateGeneric textGeneric text Generic dateGeneric textGeneric text Generic dateGeneric textGeneric text
1
2
3

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text
Is there any information on available records, reports or letters that N has ever:
-
attended hospital outpatients or special(ist) clinic?
been admitted to hospital?
been in-care, fostered, or in other residential placement?
If yes ringed to (a), (b) or (c),
qc_6_a-c == 1
please give any recorded details below for each condition for which seen at hospital or admitted, and for any occasion fostered or in care or other residential placement.
Date Hosp. OP/IP or placement Details of illness and diagnosis or reason for placement Name and address in full of hospital or placement
Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text
1
2
3

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text

Has N ever had any injury considered or suspected to be "non-accidental"?

1
Yes, has had suspected or confirmed condition of this type
2
No, but has been considered to be "at risk" of this
3
No, never
0
Not known

Comments:

Generic text

Has N's name ever been included on a Register of any sort?

1
Yes - on one register
2
Yes - on more than one register
3
No, never on any register
0
Not known
A register is a means of identifying children with special needs or those who require follow-up. It is usually kept in the form of a list, card index, master file or on a computer.
If yes,
qc_8 == 1 || qc_8 == 2

was it because N is/was considered to be:

1
"At risk"/in need of observation, for medical reasons?
2
"At risk"/in need of observation, for social reasons?
3
Handicapped?
4
Other situation, specify
0
Reason not known
Please give details below from each register on which N's name has ever been placed.
Give name by which register known Who "keeps" register? * Reasons in detail why N included on this register Date first put on register If taken off, give date
Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date
First Register
Second Register
* Indicate if "peripheral" register, e.g. initiated by and confined in use to a particular clinic; or if a "central" register, e.g. initiated and kept by L.H.A./Area/District or Board.

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text

Has a decision ever been reached by a Local Education Authority that N is in need of 'special educational treatment'?

1
No - and not likely to be required
2
No - but a decision pending
3
Yes - but waiting for a place
4
Yes - and receiving special educational treatment
0
Not known
If yes, or if a decision is pending,
qc_9 == 2 || qc_9 == 3 || qc_9 == 4

into which category does child fall?

1
Blind
2
Partially sighted
3
Deaf
4
Partially hearing
5
Mentally handicapped (Scotland)
6
Educationally subnormal (Eng. & Wales)
7
Severely E.S.N. (Eng. & Wales)
8
Epileptic
9
Maladjusted
10
Physically handicapped
11
Speech defect
12
Delicate (Eng. & Wales)

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text

In summary, is there any indication from records and reports available to you that N has now or has had in the past any developmental problem, or any disability or any handicapping condition - physical, mental or emotional, irrespective of whether condition is mentioned elsewhere in this questionnaire?

1
Yes - currently
2
Yes - in past
3
No
0
Not known
If yes,
qc_10 == 1 || qc_10 == 2
list each developmental problem, disability or handicapping condition in N:
-
1
2
3
4

Comments, e.g. Notes unclear, extra information, etc.

Generic text

Is there any period in N's life for which it is known that either main H.V. records or C.H.C. records have been destroyed or lost or are unobtainable for any other reason, resulting in the present H.V. or C.H.C. records being incomplete for that period of N's life? H.V. records

1
No - no records known to be missing
2
Yes - records known missing for part of N's life
3
Yes - records known missing for all of N's life
4
Other answer, specify

Is there any period in N's life for which it is known that either main H.V. records or C.H.C. records have been destroyed or lost or are unobtainable for any other reason, resulting in the present H.V. or C.H.C. records being incomplete for that period of N's life? C.H.C. records

1
No - no records known to be missing
2
Yes - records known missing for part of N's life
3
Yes - records known missing for all of N's life
4
Other answer, specify
If 2 or 3 ringed in either column, give further details below.
qc_11_i == 2 || qc_11_i == 3 || qc_11_ii == 2 || qc_11_ii == 3

Approximate time period to which missing records relate. Please give dates. From ... To ... H.V. records

Generic date
Generic date 1

Approximate time period to which missing records relate. Please give dates. From ... To ... C.H.C. records

Generic date
Generic date 1

Please give reason why record(s) not available. H.V. records

1
Destroyed, lost, etc., i.e. no longer exists
2
Record(s) elsewhere or in transit, i.e. exists but not available
3
Other reason, specify
0
Reason not known

Please give reason why record(s) not available. C.H.C. records

1
Destroyed, lost, etc., i.e. no longer exists
2
Record(s) elsewhere or in transit, i.e. exists but not available
3
Other reason, specify
0
Reason not known

Comments, e.g. Extra information etc.

Generic text

Have any of the following records been used for the completion of this schedule?

1
Records of any developmental screening in G.P.'s surgery/health centre
2
Handicap record(s), e.g. 2 HP, 4 HP, specify
3
Medical records of nursery school/class or infant school
4
Medical records of day nursery or other day-care
5
Medical records of residential nursery or other residential care
6
Other record(s) or source(s) of information, namely
Other

Comments, e.g. Notes unclear, records absent, extra information, etc.

Generic text

Name(s) of person(s) completing this Schedule

Generic text

Professional status

Generic text

Employing Area Health Authority/Health Board

Generic text

Date of completion of Schedule

Generic date
Please use this page to give further details of any questions if insufficient space in the questionnaire.

Please write in your own words a short account of the impression you have gained from the records of this child's health and health care in the first five years and also whether there are any environmental, social or family factors which you consider to be important.

Long text
THANK YOU VERY MUCH FOR ALL YOUR HELP
End

bcs_75_dhs

Child Health and Education in the Seventies
Under the auspices of the University of Bristol and the National Birthday Trust Fund
Director: Professor Neville R. Butler, MD, FRCP, DCH
Department of Child Health Research Unit University of Bristol
CONFIDENTIAL
DEVELOPMENTAL HISTORY SCHEDULE
Health District Code
Generic text
Child's Local Serial Number
Generic text
Child's Central Survey Number
Generic text
Full Name of the Child
Generic text
Sex
Generic text
Address
Generic text
Date of birth
Date of birth
name of previous A.H.A./L.H.A., or Health Board
Generic text
age (approx. in years and months) of N when moved to present A.H.A./L.H.A./Health Board
Generic text
Notes for Completion of Schedule
The purpose of this Schedule is to obtain data on the utilisation by the study child of child health clinics, health visiting facilities, developmental screening tests and other important aspects of the community health services. As parental recall of past events is often incomplete, reference to pre-school child health records is also essential as a means of confirming and supplementing information obtained by the Health Visitor in the home interview.
2. Person(s) Completing Schedule
Ideally the Health Visitor who is carrying out the home interview should also complete this schedule. Some of the information may require access to records usually held centrally, such as in Area or Distict Offices or in Health Boards (Scotland), e.g. special handicap records, centrally held registers. The personnel used and arrangements made for completion will doubtless be decided by the Area or District officer responsible according to local contingency.
3. Records Required
(a) The following basic types of records are essential for the main part of this schedule.
(i) Records used by health visitor to record health visiting, e.g. Home Visiting records, Consultation Record Cards and, where available, Family Records. These will be referred to as H.V. records,
(ii) Records used in Child Health Clinics or Child Welfare Clinics by doctors to record developmental screening and other health care, e.g. MCW 46. These will be referred to as C.H.C. records.
(b)Some questions require reference to other sources, in addition to the above basic records - for children for whom there may be letters or reports indicating past hospital outpatient attendances or inpatient care, children who are on observation or other registers, children who have been assessed for special educational treatment and other children who have handicaps or disabilites. In some instances, this information will be available in H.V.'s or C.H.C. records, but arrangements will probably be necessary for this to be supplemented from records or information held centrally.
(c) Records about developmental screening are needed for question 4. The majority of general developmental check-ups and specific screening tests will be recorded on records used by doctors in Child Health Clinics and on H.V. records. Additional information about any developmental check-ups at G.P. practices or health centres would be valuable, and may be readily available to health visitors attached to G.P. practices. Developmental check-ups are sometimes carried out elsewhere, e.g. at hospital birth follow-up clinics, and vision and hearing are often screened during routine medical examination at day nursery, nursery and infant school. This information would be appreciated if it is readily available.
4. Developmental Screening & Assessment
Developmental screening in Q.4 refers to check-ups usually routinely performed on all pre-school children to identify those who may be developmentally delayed or have a suspected vision or hearing defect.
Developmental assessment in Q.5 refers to a much more detailed examination of development, which is usually only performed on children who have already been identified as having a possible delay or defect in hearing, vision or other aspect of development.
What to include as Developmental Screening in Q.4 Part I
(a) Any record of a routine general developmental examination or a check-up of overall developmental progress.
This term does not refer to an isolated single screening test, though specific screening tests may often be included in the general observations and examination made of the child's developmental achievements. General developmental examinations or check-ups of overall developmental progress are usually carried out at or near prescribed ages in C.H.C, home or G.P.'s practices by doctor or health visitor. The result is often entered on C.H.C. or H.V. records under several headings of 'developmental' function e.g. hearing and language, posture and locomotion, vision, social behaviour, or may be entered in the form of observations of individual developmental achievements of the child, e.g. sitting, smiling, saying single words, etc. If neither of these forms of recording are present in the notes, but it is definitely indicated that a general developmental check-up was made, this should be included. Please include also any record you may have of a general medical examination or check-up carried out by a doctor at nursery or infant school.
(b)Any record of tests for vision, hearing or squint.
Vision and hearing may be tested on their own or as part of a general developmental examination or check-up of overall developmental progress. They are routine clinical procedures used for testing these special functions, e.g. routine testing of hearing by rattle, paper etc. by H.V. at 7-9 months, screening of vision by Stycar 5-letter test at age 3 years. If the details of the type of test used are not clear but the records indicate that vision, hearing or both have been checked, such entries should be included as vision or hearing tests.
Any record that there has been a check-up for a squint should be entered separately as "examination for squint" and not be entered as a vision test in section b of the table in Q.4. Include as "examination for squint" any occasion where records indicate a specific test was made, e.g. cover test or light reflection test, or where the records indicate only if a squint was, or was not, evident in the course of a general examination. Records of any such test(s) for vision, hearing or squint carried out at nursery or infant school should also be included.
(c) Please exclude from Q.4 Part I any remarks or observations of developmental progress made at times other than the developmental screening examinations and tests described above. Details of these should be entered in Q.4 Part II.
5. General Notes
(a) Every question should be answered.
(b)Please base your answers only on information which is contained in the record form(s), registers etc. There is space provided below each question for you to add any information known to you from other sources.
(c) If you have any difficulty in interpreting or reading the relevant entry on records, ring code marked "records unclear" and give details in the space for "comments" at the end of the question.
(d)If you do not have the relevant record(s) at all when answering a question, please ring code marked "No records".
(e) Allowance should be made for the fact that the format of every question inevitably cannot correspond with all the different recording systems in use throughout the country. Space is therefore provided at the end of each question for comments, and for supplying extra data such as:
(i) additional information known to you but not on the records;
(ii) details of any difficulties with obtaining or interpreting the data on the relevant record;
(iii) other observations, e.g. where the information given on records is considered not to reflect a true picture of the actual events.
(f) Some abbreviations are used in this schedule, e.g.
Study Child ... ... ... ... ... ... N
Health Vistor records ... ... ... ... ... H.V. records
Child Health Clinic records used by doctor ... C.H.C. records
Local Health Authority ... ... ... ... L.H.A.
Area Health Authority ... ... ... ... A.H.A.
Phenylketonuria ... ... ... ... ... P.K.U.
Question ... ... ... ... ... ... Q
(g) Further details about C.H.E.S. and on the completion of questions are given in "Survey Notes and Information".
ALL INFORMATION RECORDED ON THIS SCHEDULE WILL BE TREATED AS STRICTLY CONFIDENTIAL IN ACCORDANCE WITH MEDICAL RESEARCH COUNCIL REGULATIONS AND NO CHILD WILL BE IDENTIFIED OR REFERRED TO IN ANY REPORT BY NAME.
Do the Health Visitor's records or child health clinic records indicate that N has ever had for any reason whatsoever - any home visit from H.V.?
1
Yes
2
No
3
Records unclear
0
No records
Do the Health Visitor's records or child health clinic records indicate that N has ever had for any reason whatsoever - any attendance at C.H.C.?
1
Yes
2
No
3
Records unclear
0
No records
Give date of first H.V. visit* and first C.H.C. attendance for any reason whatever. First H.V. home visit*
Generic date
Give date of first H.V. visit* and first C.H.C. attendance for any reason whatever. First C.H.C. attendance
Generic date

Give the total number of visits from H.V. and N's C.H.C. attendances for any reason whatsoever, in each time-period specified below.

Total number of H.V. home visits * Total number of C.H.C. attendances
How manyHow many How manyHow many
First year: Child's age in months 0-5: Time period Apr. 1970 - Sep. 1970
First year: Child's age in months 6-11: Time period Oct. 1970 - Mar. 1971
Second year: Child's age in months 12-17: Time period Apr. 1971 - Sep. 1971
Second year: Child's age in months 18-23: Time period Oct. 1971 - Mar. 1972
Third year: Child's age in months 24-29: Time period Apr. 1972 - Sep. 1972
Third year: Child's age in months 30-35: Time period Oct. 1972 - Mar. 1973
Fourth year: Child's age in months 36-47: Time period Apr. 1973 - Mar. 1974
Fifth year: Child's age in months 48+: Time period Since April 1974
Total since birth
* Exclude any visit where no access gained to home and note such visits in "comments" below.
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text
Please state if H.V. or C.H.C. records indicate that N's history contains any risk factors - either as a complication or condition which occurred during the perinatal period (pregnancy, labour, or postnatal in first week), or as a genetic, social or environmental factor.
Include the following type of entries as risk factors.
(i) Any entry of a condition of N in space specially provided on the H.V. or C.H.C. record form for risk (or similarly named) factors, or any entry of a condition specified on the H.V. or C.H.C. record as reasons for inclusion in at risk/observation register.
(ii) Any condition which, though not directly labelled as a risk-factor in the above records, is implied to be a risk factor by virtue of being printed in a check-list of abnormal conditions on the H.V. or C.H.C. record form. One example of such a list is on the front page of C.H.C. record MCW 46.
Include all above conditions, irrespective of whether N's name was actually placed on a Register or not.
Is there any risk factor recorded: on H.V. records?
1
Yes
2
No
3
Record Unclear
0
No records
Is there any risk factor recorded: on C.H.C. records?
1
Yes
2
No
3
Record Unclear
0
No records

ring any condition(s) listed below which correspond to risk-factor(s) reported in N's records. Ring risk factor(s) reported from H.V. records separately from C.H.C. records. If any risk factor(s) reported in N's records do not correspond exactly or nearly exactly to any condition listed below, ring the category 'other risk factor' and specify the nature of the risk-factor in the space provided.

Pregnancy/Delivery Other risk factor in pregnancy/labour, specify First week of N's life Other risk factor(s) specify Social or Genetic Social or environmental risk factor(s), specify Genetic risk factor(s), specify

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther

1 - Rubella in first 4 mths

2 - Twin pregnancy

3 - Rh or ABO incompatibility

4 - Hypertension, toxaemia

5 - Any pregnancy bleeding

6 - Psychiatric illness

7 - Diabetes

8 - Gestation under 36/37 wks

9 - Postmaturity (42 wks+)

10 - Breech

11 - Prolonged/diffic. labour

12 - Foetal distress

13 - Other risk factor in pregnancy/labour, specify

Other

1 - Low birthweight

2 - Birth asphyxia

3 - Jaundice

4 - Convulsions

5 - Any cong. abnorm.

6 - Resp. distress

7 - Other risk factor(s) specify

Other

1 - Social or environmental risk factor(s), specify

2 - Genetic risk factor(s), specify

OtherOther
H.V. record
C.H.C. record
Where "combined" record used, with both H.V. and C.H.C. doctor's entries, ring both columns and note "combined record" in comments below.
Comments, e.g. Notes unclear, records absent, extra information etc.
Generic text
Please refer to notes 3(c) and 4(a-c) at the beginning of this schedule concerning Q.s 3-4.
Do the records specified below contain any indication that the following have been done? Is there a record of: From H.V. or C.H.C. records only N's birthweight?
1
Yes
2
No
3
Records unclear
4
No Records
specify ... lbs ... oz or ... gm
lbs
oz in pounds
gm
Do the records specified below contain any indication that the following have been done? Is there a record of: From H.V. or C.H.C. records only N's gestational maturity?
1
Yes
2
No
3
Records unclear
4
No Records
specify ... wks
wks
Do the records specified below contain any indication that the following have been done? Is there a record of: From H.V. or C.H.C. records only Any congenital defect in N?
1
Yes
2
No
3
Records unclear
4
No Records
specify specify
Generic text

Do the records specified below contain any indication that the following have been done? Is there a record of:

-
Any screening for P.K.U.?
Any screening for CDH (hip)?
Any screening for hearing?
Any screening for squint?
Any screening for vision?
Any gen. devlp. check-up(s)?
If yes to (f), (g), (h) or (i), please ensure that each test or check-up is entered in Q.4.
Comments, Notes unclear, records absent, extra information, etc.
Generic text

Part I Please complete table below for each occasion N received developmental screening (exclude P.K.U./hip tests) - either a general developmental examination or check-up or a screening test of hearing, vision or squint, (see notes on page 2).

When "screened"? What was done? Ring all that apply Who screened N? Where screened?
Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

Generic date

1 - Genl. devel. check-up

2 - Hearing test

3 - Vision test

4 - Exam. for squint

1 - Doctor

2 - Health visitor

3 - Other or uncertain

0 - Not known who

1 - Child Health Clinic

2 - G.P.'s practice

3 - N's home

4 - Nursery/Infant school

5 - Hospital birth follow-up clinic

6 - Other or uncertain

1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
Note that only the fact that N was tested is to be entered in the answer to this question; details of any referral for assessment or for further investigations for suspected delay or abnormality should be recorded in Q.5.
Notes for completion of section (b) in table below.
Whenever records indicate that a routine general developmental check-up or examination was made, ring 1. If a hearing test, a vision test and/or an examination for squint was included as part of this general developmental check-up, ring 2, 3 and/or 4 as appropriate. If a comprehensive developmental scale, e.g. Denver or Griffiths, was used, ring 1, 2 and 3 even though individual components may not be specified; please name any such scale used in "comments" below the table. Ring 2, 3 and/or 4 in section (b) if screening for hearing, vision and/or squint was done on occasion(s) separate from a general developmental check-up.
In answering section (c) below, give the main person responsible if more than one person carried out tests or made observations on any one occasion.
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text

Part II Please enter below the details of any observations of developmental progress which have been made at times other than on the occasions of routine developmental screening examinations or tests, described in Part I. If not known by whom or where observed put NOT KNOWN. If more space required, please continue on back page of schedule.

Date Who observed N? H.V. or Dr. Where observed C.H.C./home/G.P.'s etc. Summary of observations recorded
Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text
1
2
3
4

Is there any information on available records, reports or letters that N has ever been seen for assessment (see note 4 on second page) or for further tests, as a result of a (suspected) defect in hearing or vision or any other developmental problem? Include assessments in special assessment/handicap centres as well as hospital OP/IP situation.

-
specialist hearing assessment or further hearing tests
specialist visual assessment or further eye tests
specialist or further assessment for any other developmental problem.*
*e.g. delay in motor, intellectual, mental, language, social or emotional development.

please give details below for each referral.

Date Problem for which referred, diagnosis if recorded, and any further details Name and address in full of hospital, clinic, or assessment centre
Generic dateGeneric textGeneric text Generic dateGeneric textGeneric text Generic dateGeneric textGeneric text
1
2
3
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text

Is there any information on available records, reports or letters that N has ever:

-
attended hospital outpatients or special(ist) clinic?
been admitted to hospital?
been in-care, fostered, or in other residential placement?

please give any recorded details below for each condition for which seen at hospital or admitted, and for any occasion fostered or in care or other residential placement.

Date Hosp. OP/IP or placement Details of illness and diagnosis or reason for placement Name and address in full of hospital or placement
Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text Generic dateGeneric textGeneric textGeneric text
1
2
3
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text
Has N ever had any injury considered or suspected to be "non-accidental"?
1
Yes, has had suspected or confirmed condition of this type
2
No, but has been considered to be "at risk" of this
3
No, never
0
Not known
Comments:
Generic text
Has N's name ever been included on a Register of any sort?
1
Yes - on one register
2
Yes - on more than one register
3
No, never on any register
0
Not known
A register is a means of identifying children with special needs or those who require follow-up. It is usually kept in the form of a list, card index, master file or on a computer.
was it because N is/was considered to be:
1
"At risk"/in need of observation, for medical reasons?
2
"At risk"/in need of observation, for social reasons?
3
Handicapped?
4
Other situation, specify
0
Reason not known

Please give details below from each register on which N's name has ever been placed.

Give name by which register known Who "keeps" register? * Reasons in detail why N included on this register Date first put on register If taken off, give date
Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date Generic textGeneric textGeneric textGeneric dateGeneric date
First Register
Second Register
* Indicate if "peripheral" register, e.g. initiated by and confined in use to a particular clinic; or if a "central" register, e.g. initiated and kept by L.H.A./Area/District or Board.
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text
Has a decision ever been reached by a Local Education Authority that N is in need of 'special educational treatment'?
1
No - and not likely to be required
2
No - but a decision pending
3
Yes - but waiting for a place
4
Yes - and receiving special educational treatment
0
Not known
into which category does child fall?
1
Blind
2
Partially sighted
3
Deaf
4
Partially hearing
5
Mentally handicapped (Scotland)
6
Educationally subnormal (Eng. & Wales)
7
Severely E.S.N. (Eng. & Wales)
8
Epileptic
9
Maladjusted
10
Physically handicapped
11
Speech defect
12
Delicate (Eng. & Wales)
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text
In summary, is there any indication from records and reports available to you that N has now or has had in the past any developmental problem, or any disability or any handicapping condition - physical, mental or emotional, irrespective of whether condition is mentioned elsewhere in this questionnaire?
1
Yes - currently
2
Yes - in past
3
No
0
Not known

list each developmental problem, disability or handicapping condition in N:

-
1
2
3
4
Comments, e.g. Notes unclear, extra information, etc.
Generic text
Is there any period in N's life for which it is known that either main H.V. records or C.H.C. records have been destroyed or lost or are unobtainable for any other reason, resulting in the present H.V. or C.H.C. records being incomplete for that period of N's life? H.V. records
1
No - no records known to be missing
2
Yes - records known missing for part of N's life
3
Yes - records known missing for all of N's life
4
Other answer, specify
Is there any period in N's life for which it is known that either main H.V. records or C.H.C. records have been destroyed or lost or are unobtainable for any other reason, resulting in the present H.V. or C.H.C. records being incomplete for that period of N's life? C.H.C. records
1
No - no records known to be missing
2
Yes - records known missing for part of N's life
3
Yes - records known missing for all of N's life
4
Other answer, specify
Approximate time period to which missing records relate. Please give dates. From ... To ... H.V. records
Generic date
Generic date 1
Approximate time period to which missing records relate. Please give dates. From ... To ... C.H.C. records
Generic date
Generic date 1
Please give reason why record(s) not available. H.V. records
1
Destroyed, lost, etc., i.e. no longer exists
2
Record(s) elsewhere or in transit, i.e. exists but not available
3
Other reason, specify
0
Reason not known
Please give reason why record(s) not available. C.H.C. records
1
Destroyed, lost, etc., i.e. no longer exists
2
Record(s) elsewhere or in transit, i.e. exists but not available
3
Other reason, specify
0
Reason not known
Comments, e.g. Extra information etc.
Generic text
Have any of the following records been used for the completion of this schedule?
1
Records of any developmental screening in G.P.'s surgery/health centre
2
Handicap record(s), e.g. 2 HP, 4 HP, specify
3
Medical records of nursery school/class or infant school
4
Medical records of day nursery or other day-care
5
Medical records of residential nursery or other residential care
6
Other record(s) or source(s) of information, namely
Other
Comments, e.g. Notes unclear, records absent, extra information, etc.
Generic text
Name(s) of person(s) completing this Schedule
Generic text
Professional status
Generic text
Employing Area Health Authority/Health Board
Generic text
Date of completion of Schedule
Generic date
Please use this page to give further details of any questions if insufficient space in the questionnaire.
Please write in your own words a short account of the impression you have gained from the records of this child's health and health care in the first five years and also whether there are any environmental, social or family factors which you consider to be important.
Long text
THANK YOU VERY MUCH FOR ALL YOUR HELP
Name

Developmental History Schedule