Start
nshd_57_sd
STRICTLY CONFIDENTIAL
JANUARY 1957
EXAMINATION BY THE SCHOOL DOCTOR
NATIONAL SURVEY OF THE HEALTH AND DEVELOPMENT OF CHILDREN
INSTITUTE OF CHILD HEALTH (UNIVERSITY OF LONDON) SOCIETY OF MEDICAL OFFICERS OF HEALTH and POPULATION INVESTIGATION COMMITTEE At the LONDON SCHOOL OF ECONOMICS,

Ref. No.

Generic text

Name

Generic text

Address

Long text

School

Generic text
FOR THOSE WHO HAVE MOVED

New Address

Long text

L.E.A.

Generic text

School

Generic text
IF THE FAMILY HAS MOVED TO ANOTHER AUTHORITY PLEASE ENTER THE NEW ADDRESS AND THE NAMES OF THE NEW L.E.A. AND NEW SCHOOL IN THE SPACE PROVIDED. IF THE CHILD CANNOT BE TRACED PLEASE ENTER THE LAST ADDRESS AND ANY OTHER INFORMATION THAT MIGHT HELP US TO TRACE HIM. IN EITHER CASE RETURN THE FORM TO WHOMEVER HAS BEEN DELEGATED BY THE SCHOOL MEDICAL OFFICER TO RECIEVE IT.
Purpose of this enquiry.
This child was enrolled at birth in a national survey which is being made by a Joint Committee of the Institute of Child Health, the Society of Medical Officers of Health and the Population Investigation Committee. They are drawn from all social classes and during the first ten years of their lives only 8 per cent. of the children in the original sample have been lost. The value of this inquiry depends on information being obtained for every possible survey child. The Joint Committee are therefore most anxious that this form should be completed.
How to fill in this form.
Five thousand children scattered all over the country are being given this examination, and it is therefore important that the many hundreds of doctors who are examining them should record their findings in a comparable way. For this reason, and also to reduce the amount of clerical work, this examination form has been framed as a series of questions, many of which can be answered by one of several printed alternatives. All that is required is to put a circle round the number opposite the printed answer that most nearly describes your findings. If no alternative fits please write the answer in the space directly under the question. Similarly, if you feel that any printed answer, though applicable, does not fully explain your findings, we should be most grateful for any further information you can give us. When a question does not apply it should be struck through. When either the Doctor or the Mother is unable to answer a question, this fact should be recorded in the space directly under the question.
In order to ensure that these many medical histories are obtained in the same way it is important, when questioning the parent, that the wording and order of this form should be adhered to.
COMPLETED FORMS SHOULD BE RETURNED TO THE SCHOOL MEDICAL OFFICER AND NOT DIRECTLY TO THE JOINT COMMITTEE
It is hoped that the Mother &/or Father will be present at this examination
A. MEDICAL HISTORY
Put a circle round the code number opposite the printed answer that most nearly describes your findings. If no alternative fits please write the answer in the space directly under the question.
If a question does not apply, strike it through.
SURVIVAL
If this child has died please state

Date of Death

Date of death

Cause of Death (if known)

Generic text

Address or Name of Hospital where death occurred

Generic text
SOURCE OF INFORMATION

If this child is living but the form cannot be completed please state the reason here :

Generic text

Parent or relative attending with child

1
Mother
2
Father
3
Both parents
*
Other person, namely
0
No one
Other
ASTHMA

Has this child, during the last year, had an attack of asthma?

1
Yes
0
No
(If "yes".)
qc_4_a == 1

How frequent are his asthmatic attacks?

Generic text

How long do they last? ... hours

How many

Has a doctor been consulted about his asthma?

1
Doctor consulted
0
No doctor consulted

Has the cause of the attacks been investigated?

1
Yes, at hospital
2
Yes, by family doctor
0
No investigation

Name and address of hospital where investigated Name

Generic text

Name and address of hospital where investigated Address

Generic text

What treatment is being given?

Generic text
TEETH

How many times has this child been seen by a dentist during the last year? ... times

How many
0
A_HEART

During the last year, has this child been treated for heart trouble?

1
Yes
0
No
(If "yes".)
qc_6_a == 1

What treatment was given?

Generic text

Did this treatment lead to any restriction of his activities?

*
Yes, namely
0
No restriction of activities
Generic text
A_ABDOMEN

Has this child had any attacks of abdominal pain during the last year?

1
Yes
0
No
(If "yes".)
qc_7_a == 1

Was a doctor called in or was he taken to hospital?

1
Doctor called in
2
Taken to hospital
0
Neither

Has this child, during the last year, had recurrent attacks of vomiting (i.e. out of sorts at least 12 hours and at least one vomit)?

1
Yes
0
No
(If "yes".)
qc_8_a == 1

About how often does he have these attacks?

1
Less than once a month
2
More often

Are these attacks associated with any particular circumstances? If so, please give details

Generic text
(All Children)

Has this child ever had jaundice or putty coloured stools?

1
Yes
0
No
(If "yes".)
qc_8_d == 1

Please give details

Generic text
BEDWETTING

Is this child now dry by night?

0
Never wet
1
Wet occasionally
2
Wet several nights a week
3
Wet every night
(If "wet")
qc_9_a == 1 || qc_9_a == 2 || qc_9_a == 3

How are you trying to get him dry?

Generic text
MENSTRUATION

Has this child started her periods?

1
Yes
0
No
Y
Does not apply
HEARING

Is this child hard of hearing sometimes, or all the time?

1
Sometimes deaf
2
Always deaf
0
Normal hearing
(If "sometimes deaf".)
qc_11_a == 1

Is he hard of hearing when he has colds?

1
Yes
2
No
FITS AND CONVULSIONS

Has this child, during the last year, had a fit or convulsion or lost consciousness?

1
Yes, fits, etc.
0
No fit or convulsion
(If "fit or convulsion".)
qc_12_a == 1

How many fits or convulsions has he had during the last year? ... fits and convulsions

How many

Did they occur during an illness or while he was in normal health?

1
During an illness
2
While in normal health
GENERAL HEALTH

Are you in any way worried about this child's health?

1
Yes
0
No
(If "yes".)
qc_13_a == 1

Please give your reasons for worrying

Generic text
X-RAY
Please give the following details of any X-rays (including mass miniature radiography) this child has ever had.
Approx. age Reason for X-ray Part X-rayed Approximate number of exposures
How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text
1
2
3
B. EXAMINATION

Pulse rate at beginning of examination ... per minute

How many
THROAT AND TONSILS

Colour of pillars of fauces.

1
Congested
0
Not congested
Y
Not seen, child gags

Tonsils.

1
Present and intact
2
Remnants
0
Removed
Y
Not seen, child gags
(If tonsils present.)
qc_16_b == 1

Size of tonsils.

1
Meet in mid line
2
Buried and atrophic
3
All other sizes

Crypts.

1
Contain pus
2
Do not contain pus
3
No crypts seen
4
Concretions

Tonsillar glands.

1
Palpable
0
Not palpable

In your opinion should this child's tonsils be removed?

1
Yes
0
No
2
Undecided
(If "yes".)
qc_16_f == 1

Please give your reasons

Generic text
TEETH

Please describe the condition of the FIRST PREMOLAR TEETH Number missing

How many

Please describe the condition of the FIRST PREMOLAR TEETH Number filled

How many

Please describe the condition of the FIRST PREMOLAR TEETH Number decayed, not filled

How many

Please describe the condition of the FIRST PREMOLAR TEETH Number non-carious

How many
BREAST DEVELOPMENT

Are there any signs of breast development?

1
Yes
0
No
Y
Does not apply
LUNGS

Are there any abnormal signs present in the lungs?

1
Abnormal signs present
0
No abnormality detected
(If "abnormal signs".)
qc_19 == 1

Please describe

Generic text
B_HEART
Please examine this child standing up and lying down.

Position of cardiac impulse

Generic text

Murmurs. Standing

0
No murmur heard
1
Murmur(s) heard

Murmurs. Lying

0
No murmur heard
1
Murmur(s) heard
(If "murmur(s)".)
qc_20_b_i == 1 || qc_20_b_ii == 1

Point of maximum intensity?

Generic text

Timing of the murmur?

Generic text

Is there a palpable thrill?

Generic text

If so, where?

Generic text
(All children.)

Details of any other cardiac abnormalities not noted above

Generic text

Do you consider that this child shows any evidence of rheumatic heart disease?

1
Yes
0
No
2
Doubtful
(If "yes")
qc_20_d == 1

Please describe

Generic text

Are there any other manifestations of rheumatic disease

Generic text
(All children.)

Do you consider that this child shows any evidence of congenital heart disease?

1
Yes
0
No
2
Doubtful
(If "yes")
qc_20_f == 1

Please describe

Generic text
B_ABDOMEN

Is there any abdominal distention?

1
Yes
0
No

Are there any palpable masses?

0
No
1
Yes, liver palpable
2
Yes, spleen palpable
3
Yes, foeces palpable
*
Yes, other masses, namely
Other

Is there any evidence of umbilical hernia?

1
Yes
0
No

Is there an impulse on coughing when a finger is inserted into the inguinal canal?

1
Yes
0
No

Is any pigmented pubic hair visible?

1
Yes
0
No

Has this child been circumcised?

1
Yes
0
No
Y
Does not apply

Are both testicles in the scrotal sac?

1
Yes, both
2
Left only descended
3
Right only descended
4
Neither descended
Y
Question does not apply
(If "not descended")
qc_22_a == 2 || qc_22_a == 3 || qc_22_a == 4

Can the testicle(s) be drawn down into the scrotal sac?

1
Yes
0
No
MISCELLANEOUS

Lymphatic glands Neck (Exc. tonsillar glands)

1
Palpable
0
Not palpable

Lymphatic glands Axilla

1
Palpable
0
Not palpable

Lymphatic glands Groin

1
Palpable
0
Not palpable

Skin.

0
No obvious abnormality
1
Septic spots or boils
*
Other abnormalities, namely
Other

Nails and fingers.

*
No abnormality
1
Bitten nails
2
Clubbed fingers
*
Other, namely
Other

Orthopaedic defects.

0
None
1
Defect
(If "defect".)
qc_26 == 1

Please give details

Generic text

Remarks on other abnormalities or deformities not reported above

Generic text

Pulse rate at end of examination ... per minute.

How many
PHYSICAL MEASUREMENTS

Present weight. (In underpants or knickers only and WITHOUT SHOES. If this is impossible please list the clothes in which he was weighed ... ) ... st. ... lbs. ... ozs.

Generic text
st
lbs
ozs

Scales used.

1
Beam balance
2
Spring balance

Present standing height. (WITHOUT SHOES.) ... ft. ... ins.

ft.
ins.
1
Height measurer used
2
Measured against wall
["The most accurate results are obtained if heels, shoulders and buttocks touch an upright wall, and the child looks straight ahead so that the lower border of the orbit and the external auditory meatus are in the same horizontal plane. The child should be told to make himself as tall as possible without lifting his heels from the ground. A deep breath should be taken as this helps to bring him up to his maximum height." Report of C.M.O., Ministry of Education, 1950/51, p.61.]
SPEECH

Speech.

0
No abnormality
1
Stammering
2
Dyslalia
*
Structural speech defect, namely
Generic text
(If "stammering", "dyslalia" or other defect.)
qc_31_a == 1 || qc_31_a == 2 || qc_31_a == *

Does this child, in your opinion, need speech therapy?

1
Yes
0
No
(If "yes")
qc_31_b == 1

What arrangements have been made to give him speech therapy

Generic text
EYES

Squint.

0
Does not squint
1
Concomitant squint
2
Paralytic squint

Does this child wear glasses?

0
Yes
1
No
Visual acuity.
Without glasses With glasses
Generic textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric text
Right eye
Left eye

Eye defects not noted above:

Generic text
EARS

External Auditory Meatus. Right

1
Mucoid discharge
2
Purulent discharge
3
Wax
0
Clear
*
Other, namely
Other

External Auditory Meatus. Left

1
Mucoid discharge
2
Purulent discharge
3
Wax
0
Clear
*
Other, namely

Drums. Right

0
Intact
1
Indrawn
2
Perforated
3
Obscured by wax
*
Other conditions, namely
Other

Drums. Left

0
Intact
1
Indrawn
2
Perforated
3
Obscured by wax
*
Other conditions, namely
Other

What is your assessment of this child's hearing?

3
Average or good
2
Poor
1
Very poor
[If hearing is "poor")
qc_33_c == 2 || qc_33_c == 1

Does he wear a hearing aid?

Generic text
LATERALITY

Eye dominance

1
Always right eye
2
Always left eye
3
Sometimes right, sometimes left
HANDS

Which hand does this child use to write with or draw with?

1
Right
2
Left
3
Either

Ask the child to pick up a ball placed directly in front of him, and to throw it as accurately as possible into a box. Note which hand is used. Repeat three times.

1
Always right hand
2
Always left hand
3
Sometimes right, sometimes left
ASSESSMENTS

Alertness and activity.

2
Average
3
Above average
1
Below average
0
Apathetic

Physical development.

1
Average
2
Superior
0
Inferior

CHECK ON PAST INFORMATION

Long text

Name of Doctor making examination

Generic text
1
School Doctor
2
Family Doctor

Date of Examination

Generic date

Time taken for this interview

Generic time
End

nshd_57_sd

STRICTLY CONFIDENTIAL
JANUARY 1957
EXAMINATION BY THE SCHOOL DOCTOR
NATIONAL SURVEY OF THE HEALTH AND DEVELOPMENT OF CHILDREN
INSTITUTE OF CHILD HEALTH (UNIVERSITY OF LONDON) SOCIETY OF MEDICAL OFFICERS OF HEALTH and POPULATION INVESTIGATION COMMITTEE At the LONDON SCHOOL OF ECONOMICS,
Ref. No.
Generic text
Name
Generic text
Address
Long text
School
Generic text

FOR THOSE WHO HAVE MOVED

New Address
Long text
L.E.A.
Generic text
School
Generic text
IF THE FAMILY HAS MOVED TO ANOTHER AUTHORITY PLEASE ENTER THE NEW ADDRESS AND THE NAMES OF THE NEW L.E.A. AND NEW SCHOOL IN THE SPACE PROVIDED. IF THE CHILD CANNOT BE TRACED PLEASE ENTER THE LAST ADDRESS AND ANY OTHER INFORMATION THAT MIGHT HELP US TO TRACE HIM. IN EITHER CASE RETURN THE FORM TO WHOMEVER HAS BEEN DELEGATED BY THE SCHOOL MEDICAL OFFICER TO RECIEVE IT.
Purpose of this enquiry.
This child was enrolled at birth in a national survey which is being made by a Joint Committee of the Institute of Child Health, the Society of Medical Officers of Health and the Population Investigation Committee. They are drawn from all social classes and during the first ten years of their lives only 8 per cent. of the children in the original sample have been lost. The value of this inquiry depends on information being obtained for every possible survey child. The Joint Committee are therefore most anxious that this form should be completed.
How to fill in this form.
Five thousand children scattered all over the country are being given this examination, and it is therefore important that the many hundreds of doctors who are examining them should record their findings in a comparable way. For this reason, and also to reduce the amount of clerical work, this examination form has been framed as a series of questions, many of which can be answered by one of several printed alternatives. All that is required is to put a circle round the number opposite the printed answer that most nearly describes your findings. If no alternative fits please write the answer in the space directly under the question. Similarly, if you feel that any printed answer, though applicable, does not fully explain your findings, we should be most grateful for any further information you can give us. When a question does not apply it should be struck through. When either the Doctor or the Mother is unable to answer a question, this fact should be recorded in the space directly under the question.
In order to ensure that these many medical histories are obtained in the same way it is important, when questioning the parent, that the wording and order of this form should be adhered to.
COMPLETED FORMS SHOULD BE RETURNED TO THE SCHOOL MEDICAL OFFICER AND NOT DIRECTLY TO THE JOINT COMMITTEE
It is hoped that the Mother &/or Father will be present at this examination

A. MEDICAL HISTORY

Put a circle round the code number opposite the printed answer that most nearly describes your findings. If no alternative fits please write the answer in the space directly under the question.
If a question does not apply, strike it through.

SURVIVAL

Date of Death
Date of death
Cause of Death (if known)
Generic text
Address or Name of Hospital where death occurred
Generic text

SOURCE OF INFORMATION

If this child is living but the form cannot be completed please state the reason here :
Generic text
Parent or relative attending with child
1
Mother
2
Father
3
Both parents
*
Other person, namely
0
No one
Other

ASTHMA

Has this child, during the last year, had an attack of asthma?
1
Yes
0
No
How frequent are his asthmatic attacks?
Generic text
How long do they last? ... hours
How many
Has a doctor been consulted about his asthma?
1
Doctor consulted
0
No doctor consulted
Has the cause of the attacks been investigated?
1
Yes, at hospital
2
Yes, by family doctor
0
No investigation
Name and address of hospital where investigated Name
Generic text
Name and address of hospital where investigated Address
Generic text
What treatment is being given?
Generic text
How many times has this child been seen by a dentist during the last year? ... times
How many
0

A_HEART

During the last year, has this child been treated for heart trouble?
1
Yes
0
No
What treatment was given?
Generic text
Did this treatment lead to any restriction of his activities?
*
Yes, namely
0
No restriction of activities
Generic text

A_ABDOMEN

Has this child had any attacks of abdominal pain during the last year?
1
Yes
0
No
Was a doctor called in or was he taken to hospital?
1
Doctor called in
2
Taken to hospital
0
Neither
Has this child, during the last year, had recurrent attacks of vomiting (i.e. out of sorts at least 12 hours and at least one vomit)?
1
Yes
0
No
About how often does he have these attacks?
1
Less than once a month
2
More often
Are these attacks associated with any particular circumstances? If so, please give details
Generic text
(All Children)
Has this child ever had jaundice or putty coloured stools?
1
Yes
0
No
Please give details
Generic text

BEDWETTING

Is this child now dry by night?
0
Never wet
1
Wet occasionally
2
Wet several nights a week
3
Wet every night
How are you trying to get him dry?
Generic text
MENSTRUATION
Has this child started her periods?
1
Yes
0
No
Y
Does not apply

HEARING

Is this child hard of hearing sometimes, or all the time?
1
Sometimes deaf
2
Always deaf
0
Normal hearing
Is he hard of hearing when he has colds?
1
Yes
2
No

FITS AND CONVULSIONS

Has this child, during the last year, had a fit or convulsion or lost consciousness?
1
Yes, fits, etc.
0
No fit or convulsion
How many fits or convulsions has he had during the last year? ... fits and convulsions
How many
Did they occur during an illness or while he was in normal health?
1
During an illness
2
While in normal health

GENERAL HEALTH

Are you in any way worried about this child's health?
1
Yes
0
No
Please give your reasons for worrying
Generic text

Please give the following details of any X-rays (including mass miniature radiography) this child has ever had.

Approx. age Reason for X-ray Part X-rayed Approximate number of exposures
How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text How manyGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textGeneric textHow manyGeneric text
1
2
3

B. EXAMINATION

Pulse rate at beginning of examination ... per minute
How many

THROAT AND TONSILS

Colour of pillars of fauces.
1
Congested
0
Not congested
Y
Not seen, child gags
Tonsils.
1
Present and intact
2
Remnants
0
Removed
Y
Not seen, child gags
Size of tonsils.
1
Meet in mid line
2
Buried and atrophic
3
All other sizes
Crypts.
1
Contain pus
2
Do not contain pus
3
No crypts seen
4
Concretions
Tonsillar glands.
1
Palpable
0
Not palpable
In your opinion should this child's tonsils be removed?
1
Yes
0
No
2
Undecided
Please give your reasons
Generic text

TEETH

Please describe the condition of the FIRST PREMOLAR TEETH Number missing
How many
Please describe the condition of the FIRST PREMOLAR TEETH Number filled
How many
Please describe the condition of the FIRST PREMOLAR TEETH Number decayed, not filled
How many
Please describe the condition of the FIRST PREMOLAR TEETH Number non-carious
How many
BREAST DEVELOPMENT
Are there any signs of breast development?
1
Yes
0
No
Y
Does not apply

LUNGS

Are there any abnormal signs present in the lungs?
1
Abnormal signs present
0
No abnormality detected
Please describe
Generic text

B_HEART

Please examine this child standing up and lying down.
Position of cardiac impulse
Generic text
Murmurs. Standing
0
No murmur heard
1
Murmur(s) heard
Murmurs. Lying
0
No murmur heard
1
Murmur(s) heard
Point of maximum intensity?
Generic text
Timing of the murmur?
Generic text
Is there a palpable thrill?
Generic text
If so, where?
Generic text
(All children.)
Details of any other cardiac abnormalities not noted above
Generic text
Do you consider that this child shows any evidence of rheumatic heart disease?
1
Yes
0
No
2
Doubtful
Please describe
Generic text
Are there any other manifestations of rheumatic disease
Generic text
(All children.)
Do you consider that this child shows any evidence of congenital heart disease?
1
Yes
0
No
2
Doubtful
Please describe
Generic text

B_ABDOMEN

Is there any abdominal distention?
1
Yes
0
No
Are there any palpable masses?
0
No
1
Yes, liver palpable
2
Yes, spleen palpable
3
Yes, foeces palpable
*
Yes, other masses, namely
Other
Is there any evidence of umbilical hernia?
1
Yes
0
No
Is there an impulse on coughing when a finger is inserted into the inguinal canal?
1
Yes
0
No
Is any pigmented pubic hair visible?
1
Yes
0
No
Has this child been circumcised?
1
Yes
0
No
Y
Does not apply
Are both testicles in the scrotal sac?
1
Yes, both
2
Left only descended
3
Right only descended
4
Neither descended
Y
Question does not apply
Can the testicle(s) be drawn down into the scrotal sac?
1
Yes
0
No

MISCELLANEOUS

Lymphatic glands Neck (Exc. tonsillar glands)
1
Palpable
0
Not palpable
Lymphatic glands Axilla
1
Palpable
0
Not palpable
Lymphatic glands Groin
1
Palpable
0
Not palpable
Skin.
0
No obvious abnormality
1
Septic spots or boils
*
Other abnormalities, namely
Other
Nails and fingers.
*
No abnormality
1
Bitten nails
2
Clubbed fingers
*
Other, namely
Other
Orthopaedic defects.
0
None
1
Defect
Please give details
Generic text
Remarks on other abnormalities or deformities not reported above
Generic text
Pulse rate at end of examination ... per minute.
How many

PHYSICAL MEASUREMENTS

Present weight. (In underpants or knickers only and WITHOUT SHOES. If this is impossible please list the clothes in which he was weighed ... ) ... st. ... lbs. ... ozs.
Generic text
st
lbs
ozs
Scales used.
1
Beam balance
2
Spring balance
Present standing height. (WITHOUT SHOES.) ... ft. ... ins.
ft.
ins.
1
Height measurer used
2
Measured against wall
["The most accurate results are obtained if heels, shoulders and buttocks touch an upright wall, and the child looks straight ahead so that the lower border of the orbit and the external auditory meatus are in the same horizontal plane. The child should be told to make himself as tall as possible without lifting his heels from the ground. A deep breath should be taken as this helps to bring him up to his maximum height." Report of C.M.O., Ministry of Education, 1950/51, p.61.]

SPEECH

Speech.
0
No abnormality
1
Stammering
2
Dyslalia
*
Structural speech defect, namely
Generic text
Does this child, in your opinion, need speech therapy?
1
Yes
0
No
What arrangements have been made to give him speech therapy
Generic text

EYES

Squint.
0
Does not squint
1
Concomitant squint
2
Paralytic squint
Does this child wear glasses?
0
Yes
1
No

Visual acuity.

Without glasses With glasses
Generic textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric text
Right eye
Left eye
Eye defects not noted above:
Generic text

EARS

External Auditory Meatus. Right
1
Mucoid discharge
2
Purulent discharge
3
Wax
0
Clear
*
Other, namely
Other
External Auditory Meatus. Left
1
Mucoid discharge
2
Purulent discharge
3
Wax
0
Clear
*
Other, namely
Drums. Right
0
Intact
1
Indrawn
2
Perforated
3
Obscured by wax
*
Other conditions, namely
Other
Drums. Left
0
Intact
1
Indrawn
2
Perforated
3
Obscured by wax
*
Other conditions, namely
Other
What is your assessment of this child's hearing?
3
Average or good
2
Poor
1
Very poor
Does he wear a hearing aid?
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LATERALITY

Eye dominance
1
Always right eye
2
Always left eye
3
Sometimes right, sometimes left

HANDS

Which hand does this child use to write with or draw with?
1
Right
2
Left
3
Either
Ask the child to pick up a ball placed directly in front of him, and to throw it as accurately as possible into a box. Note which hand is used. Repeat three times.
1
Always right hand
2
Always left hand
3
Sometimes right, sometimes left

ASSESSMENTS

Alertness and activity.
2
Average
3
Above average
1
Below average
0
Apathetic
Physical development.
1
Average
2
Superior
0
Inferior
CHECK ON PAST INFORMATION
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Name of Doctor making examination
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1
School Doctor
2
Family Doctor
Date of Examination
Generic date
Time taken for this interview
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Name

1957 Examination by the School Doctor