Start
nshd_52_sd
STRICTLY CONFIDENTIAL
MARCH 1952
It is hoped that the Mother &/or Father will be present at this examination
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,

Name

Generic text

Address

Generic text

School

Generic text
FOR THOSE WHO HAVE MOVED

New address

Generic 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 RECEIVE IT.
Purpose of this inquiry
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. Details of health and development have been recorded at two yearly intervals during the pre-school years and it is hoped that, during the primary school period, a clinical examination will be made by the School Doctor each year and a record of illnesses made each term by the School Nurse. The aim of the present examination is to bring the medical and social history up to date, to check information previously noted, and to record the clinical state of the child. This will complete our information for the whole of the pre-school period.
This form refers to the medical history and clinical examination only. Details of the home conditions and of certain past illnesses and accidents are being recorded by the School Nurse or Health Visitor on a separate sheet.
How to fill in this form.
Six 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
If this child has died please state

Date of Death

Date of death

Cause of Death (if known)

Generic text
If this child is living but the form cannot be completed

please state the reason here:

Generic text
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.

Parent or relative attending with child.

1
Mother
2
Father
3
Both parents
*
Other person, namely
0
No one
Other
COLDS, SORE THROAT, ETC.

Does this child breathe with his mouth open in the day time?

1
Yes
0
No

Does he snore at night?

2
Always snores
1
Sometimes snores
0
Never snores

How often has he had a snuffly or running nose during the last year?

3
Continually
2
Frequently (4 or more)
1
Occasionally (3 or less)
0
Never

Has he had a sore throat during the last year? If so, how many has he had? ... sore throats

How many
0
No sore throats

Do any members of the household (other than this child) have continual or repeated colds, sore throats, coughs or catarrh?

1
Yes, colds
2
Yes, sore throats
3
Yes, coughs
4
Yes, catarrh
0
No one
(If "yes.")
qc_3_a == 1 || qc_3_a == 2 || qc_3_a == 3 || qc_3_a == 4
Please say which members of the household suffer from them (giving names and ages).
Name Age State whether cold, sore throat, cough or catarrh
Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text
1
2
3
4
TONSILS

Have this child's tonsils been removed?

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

Why were they removed?

Generic text

Has his condition been better, worse or unchanged since their removal?

1
Better
3
Worse
2
Unchanged
(If "better" or "worse.")
qc_4_c == 1 || qc_4_c == 3

Please say in what ways

Generic text
(If tonsils not removed.)
qc_4_a == 0

Has anyone suggested that his tonsils should be removed?

1
Yes, doctor
*
Yes, other person, namely
0
No
Other
If "yes."
qc_4_e == 1 || qc_4_e == *

Why was this suggested?

Generic text

Is he on a waiting list for tonsillectomy?

1
Yes
0
No
(If not on waiting list.)
qc_4_g == 0

Why is he not on a waiting list?

Generic text
COUGHS

Does this child ever have attacks of coughing when he has NOT got a cold?

2
Yes, continually
1
Yes, sometimes
0
No
(For those with coughs.)
qc_5_a == 2 || qc_5_a == 1

Has a doctor been consulted about his coughing?

1
Doctor consulted
0
No doctor consulted

When he coughs, is it at night only, in the day only, or both in the day and night?

1
Night only
2
Day only
3
Both day and night

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

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

How frequent are his asthmatic attacks?

Generic text

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
(If "investigated.")
qc_6_d == 1 || qc_6_d == 2

What was the result of the investigation?

Generic text

What treatment is being given?

Generic text
A_TEETH

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

How many
0
Not seen by a dentist

How many of his teeth have been extracted? ... teeth

How many
0
None extracted
A_HEART

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

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

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_9_a == 1

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

1
Doctor callled 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_10_a == 1

About how often does he have these attacks?

1
Less than once a month
2
More often
SPECIAL SENSES

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 deaf when he has colds?

1
Yes
2
No
(If "always deaf.")
qc_11_a == 2

When did you first suspect he was hard of hearing? At ... years old

Age

What made you suspect it?

Generic text

Has he been treated for deafness?

1
Yes
0
No
(If "yes.")
qc_11_e == 1

What treatment (Medical, Surgical or Educational) was given?

Long text

Has this child ever complained of earache?

1
Yes
0
No
(If "yes.")
qc_12_a == 1

How old was he when he first complained? ... years

Age

How many attacks of earache has he had during the last year?

1
Frequent (more than 2)
2
Occasional (2 or less)
0
None

Has this child ever had discharge of pus from his ears?

1
Yes
0
No
(If "yes.")
qc_13_a == 1
Please give the following details:-
Age at Attack Duration of Discharge in weeks Where treated Hos. I.P. Hos.O.P. Nursing Home Own Home If treated at home, who gave treatment (Doctor, Nurse, other)
AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text
1
2
3
(Attacks recorded in earlier surveys are entered in red.)

Does this child squint or has he ever squinted?

3
Always squints
2
Sometimes squints
1
Used to squint
0
Never squints
(If "squint.")
qc_14_a == 3 || qc_14_a == 2 || qc_14_a == 1

How old was this child when squint was first noticed? ... years

Age

Has treatment been given and if so, what treatment?

0
No treatment given
*
Treatment given, namely
Generic text
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_15_a == 1

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

Pulse rate at beginning of examination ... per minute

How many
APPEARANCE

Hair colour.

1
Red
2
Blond
3
Light brown
4
Dark brown
5
Black

Skin colour.

1
Rosy cheeked
2
Pale
3
Swarthy
4
Freckled
*
Other, namely
Other

Eye colour.

1
Blue
2
Brown
3
Other

Nails and fingers.

0
No abnormality
1
Bitten nails
2
Clubbed fingers
*
Other, namely
Other
PHYSICAL MEASUREMENTS
Give measurements AS RECORDED by the apparatus used and as accurasely as these allow. (in most cases this will be to the nearest QUARTER POUND and to the nearest QUARTER INCH.)

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
Stones
Pounds in stone
Ounces in pound

Scales used.

1
Beam balance
2
Spring balance

Present standing height. (WITHOUT SHOES.) (If no height measurer is available and a ruler is used to mark the position of the top of the head, please make sure that this is level when viewed from the side.) ... ft. ... ins.

Feet
Inches in foot
NASAL PASSAGES

Is there a nasal discharge?

1
Yes
0
No
(If "yes.")
qc_20_a == 1

Is it watery or mucopurulent?

1
Watery
2
Mucopurulent
(All children.)

Is there a postnasal discharge hanging down behind the uvula?

1
Yes
0
No
Y
Not seen, child gags

Are this child's nasal passages obstructed?

1
Yes, by adenoids
2
Yes, by catarrh
*
Other causes, namely
0
Not obstructed
Other
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_21_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_21_f == 1

Please give your reasons

Generic text
B_TEETH

How many teeth have been filled in? ... teeth

How many
0
None filled

How many of his existing teeth are so carious that they require extraction? ... teeth

How many
0
None require extraction
X
Undecided
LUNGS

Are there any abnormal signs present in the lungs?

1
Abnormal signs present
0
No abnormality detected
(If "abnormal signs.")
qc_23 == 1

Please describe

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

Rhythm Standing

0
Regular
1
Irregular

Rhythm Lying

0
Regular
1
Irregular
(If "irregular.")
qc_24_a_i == 1 || qc_24_a_ii == 1

Please describe the nature of the irregularity

Generic text

Murmurs. Standing

0
No murmurs heard
1
Murmur(s) present

Murmurs. Lying

0
No murmurs heard
1
Murmur(s) present
(If "murmur(s).")
qc_24_b_i == 1 || qc_24_b_ii == 1

Please describe, giving timing and location

Generic text
(All children.)

Details of any other cardiac abnormalities not noted above

Generic text
B_ABDOMEN

Is there nay evidence of hernia or weakness of the inguinal canal?

1
Yes
0
No
(If "yes.")
qc_25 == 1

Please describe

Generic text

Is there any abnormality of the external genital organs?

1
Yes
0
No
(If "yes.")
qc_26 == 1

Please describe

Generic text
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

Orthopaedic defects

0
None
1
Defect
(If "defect.")
qc_29 == 1

Please give details

Generic text

Speech

0
No abnormality
1
Stammering
2
Dyslalia
*
Structural speech defect, namely
Generic text
(If "stammering," "dyslalia" or other defect.)
qc_30_a == 1 || qc_30_a == 2 || qc_30_a == *

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

1
Yes
0
No

Is he having, or have arrangements been made for him to have speech therapy?

1
Therapy being given
2
Arrangements made
0
No provision available
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
Other

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
EYES

Squint.

1
Does not squint
0
Concomitant squint
2
Paralytic squint
Visual acuity.
Without glasses With glasses
Generic textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric text
Right eye
Left eye

If acuity not measured please state reason

Generic text

Eye defects not noted above:

Generic text
LATERALITY

Eye Dominance.

1
Uses right eye
2
Uses left eye
3
Uses either
0
Will not co-operate

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

1
Right hand
2
Left hand
3
Either hand

Footedness. Which foot does this child use to kick a ball?

1
Right foot
2
Left foot
3
Either foot

Remarks on other abnormalities or deformities not reported above

Generic text

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

How many
ASSESSMENTS

Alertness and activity.

2
Average
3
Above average
1
Below average
0
Apathetic

Physical development.

1
Average
2
Superior
0
Inferior
PARENTS' MEASUREMENTS
It would be of great value if the following information could be obtained about the parents of this child. It is realised that it may not be possible to get actual measurements in which case please give approximate figures.
Weight (in indoor clothes) ... st. Weight (in indoor clothes) ... lbs. Weight (in indoor clothes) * Height (deduct height of heels if measured in shoes) ... ft. Height (deduct height of heels if measured in shoes) ... ins. Height (deduct height of heels if measured in shoes) *

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

Mother
Father

Age of father ... years

Age

Estimate of the reliability of the medical history given by this mother.

1
Probably reliable
2
Probably unreliable
0
Undecided
CHECK OF PAST INFORMATION
THE FOLLOWING CONDITIONS WERE REPORTED IN EARLIER SURVEYS. PLEASE CHECK THEIR ACCURACY AND SUPPLY, IF POSSIBLE, THE ADDITIONAL INFORMATION ASKED FOR.
Condition Age when reported Additional information needed Doctor's comments
AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text
1
2
3
ALL QUESTIONS SHOULD BE ANSWERED (OR CROSSED OUT IF NOT APPLICABLE). PLEASE CHECK THAT THIS HAS BEEN DONE

Name of Doctor making Examination

Generic text

Date of Examination

Generic date

Time taken for this interview

Time taken
End

nshd_52_sd

STRICTLY CONFIDENTIAL
MARCH 1952
It is hoped that the Mother &/or Father will be present at this examination
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,
Name
Generic text
Address
Generic text
School
Generic text

FOR THOSE WHO HAVE MOVED

New address
Generic 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 RECEIVE IT.
Purpose of this inquiry
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. Details of health and development have been recorded at two yearly intervals during the pre-school years and it is hoped that, during the primary school period, a clinical examination will be made by the School Doctor each year and a record of illnesses made each term by the School Nurse. The aim of the present examination is to bring the medical and social history up to date, to check information previously noted, and to record the clinical state of the child. This will complete our information for the whole of the pre-school period.
This form refers to the medical history and clinical examination only. Details of the home conditions and of certain past illnesses and accidents are being recorded by the School Nurse or Health Visitor on a separate sheet.
How to fill in this form.
Six 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
Date of Death
Date of death
Cause of Death (if known)
Generic text
please state the reason here:
Generic text

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.
Parent or relative attending with child.
1
Mother
2
Father
3
Both parents
*
Other person, namely
0
No one
Other

COLDS, SORE THROAT, ETC.

Does this child breathe with his mouth open in the day time?
1
Yes
0
No
Does he snore at night?
2
Always snores
1
Sometimes snores
0
Never snores
How often has he had a snuffly or running nose during the last year?
3
Continually
2
Frequently (4 or more)
1
Occasionally (3 or less)
0
Never
Has he had a sore throat during the last year? If so, how many has he had? ... sore throats
How many
0
No sore throats
Do any members of the household (other than this child) have continual or repeated colds, sore throats, coughs or catarrh?
1
Yes, colds
2
Yes, sore throats
3
Yes, coughs
4
Yes, catarrh
0
No one

Please say which members of the household suffer from them (giving names and ages).

Name Age State whether cold, sore throat, cough or catarrh
Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text
1
2
3
4

TONSILS

Have this child's tonsils been removed?
1
Yes
0
No
Why were they removed?
Generic text
Has his condition been better, worse or unchanged since their removal?
1
Better
3
Worse
2
Unchanged
Please say in what ways
Generic text
Has anyone suggested that his tonsils should be removed?
1
Yes, doctor
*
Yes, other person, namely
0
No
Other
Why was this suggested?
Generic text
Is he on a waiting list for tonsillectomy?
1
Yes
0
No
Why is he not on a waiting list?
Generic text

COUGHS

Does this child ever have attacks of coughing when he has NOT got a cold?
2
Yes, continually
1
Yes, sometimes
0
No
Has a doctor been consulted about his coughing?
1
Doctor consulted
0
No doctor consulted
When he coughs, is it at night only, in the day only, or both in the day and night?
1
Night only
2
Day only
3
Both day and night
Has this child, during the last year, had an attack of asthma?
1
Yes
0
No
How frequent are his asthmatic attacks?
Generic text
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
What was the result of the investigation?
Generic text
What treatment is being given?
Generic text

A_TEETH

How many times has this child been seen by a dentist during the last year? ... times
How many
0
Not seen by a dentist
How many of his teeth have been extracted? ... teeth
How many
0
None extracted

A_HEART

During the last year, has this child been treated for heart trouble?
1
Yes
0
No
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 callled 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

SPECIAL SENSES

Is this child hard of hearing sometimes, or all the time?
1
Sometimes deaf
2
Always deaf
0
Normal hearing
Is he deaf when he has colds?
1
Yes
2
No
When did you first suspect he was hard of hearing? At ... years old
Age
What made you suspect it?
Generic text
Has he been treated for deafness?
1
Yes
0
No
What treatment (Medical, Surgical or Educational) was given?
Long text
Has this child ever complained of earache?
1
Yes
0
No
How old was he when he first complained? ... years
Age
How many attacks of earache has he had during the last year?
1
Frequent (more than 2)
2
Occasional (2 or less)
0
None
Has this child ever had discharge of pus from his ears?
1
Yes
0
No

Please give the following details:-

Age at Attack Duration of Discharge in weeks Where treated Hos. I.P. Hos.O.P. Nursing Home Own Home If treated at home, who gave treatment (Doctor, Nurse, other)
AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text
1
2
3
(Attacks recorded in earlier surveys are entered in red.)
Does this child squint or has he ever squinted?
3
Always squints
2
Sometimes squints
1
Used to squint
0
Never squints
How old was this child when squint was first noticed? ... years
Age
Has treatment been given and if so, what treatment?
0
No treatment given
*
Treatment given, namely
Generic text

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 or 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

B. EXAMINATION

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

APPEARANCE

Hair colour.
1
Red
2
Blond
3
Light brown
4
Dark brown
5
Black
Skin colour.
1
Rosy cheeked
2
Pale
3
Swarthy
4
Freckled
*
Other, namely
Other
Eye colour.
1
Blue
2
Brown
3
Other
Nails and fingers.
0
No abnormality
1
Bitten nails
2
Clubbed fingers
*
Other, namely
Other

PHYSICAL MEASUREMENTS

Give measurements AS RECORDED by the apparatus used and as accurasely as these allow. (in most cases this will be to the nearest QUARTER POUND and to the nearest QUARTER INCH.)
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
Stones
Pounds in stone
Ounces in pound
Scales used.
1
Beam balance
2
Spring balance
Present standing height. (WITHOUT SHOES.) (If no height measurer is available and a ruler is used to mark the position of the top of the head, please make sure that this is level when viewed from the side.) ... ft. ... ins.
Feet
Inches in foot

NASAL PASSAGES

Is there a nasal discharge?
1
Yes
0
No
Is it watery or mucopurulent?
1
Watery
2
Mucopurulent
(All children.)
Is there a postnasal discharge hanging down behind the uvula?
1
Yes
0
No
Y
Not seen, child gags
Are this child's nasal passages obstructed?
1
Yes, by adenoids
2
Yes, by catarrh
*
Other causes, namely
0
Not obstructed
Other

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

B_TEETH

How many teeth have been filled in? ... teeth
How many
0
None filled
How many of his existing teeth are so carious that they require extraction? ... teeth
How many
0
None require extraction
X
Undecided

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.
Rhythm Standing
0
Regular
1
Irregular
Rhythm Lying
0
Regular
1
Irregular
Please describe the nature of the irregularity
Generic text
Murmurs. Standing
0
No murmurs heard
1
Murmur(s) present
Murmurs. Lying
0
No murmurs heard
1
Murmur(s) present
Please describe, giving timing and location
Generic text
(All children.)
Details of any other cardiac abnormalities not noted above
Generic text

B_ABDOMEN

Is there nay evidence of hernia or weakness of the inguinal canal?
1
Yes
0
No
Please describe
Generic text
Is there any abnormality of the external genital organs?
1
Yes
0
No
Please describe
Generic text

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
Orthopaedic defects
0
None
1
Defect
Please give details
Generic text
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
Is he having, or have arrangements been made for him to have speech therapy?
1
Therapy being given
2
Arrangements made
0
No provision available

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
Other
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

EYES

Squint.
1
Does not squint
0
Concomitant squint
2
Paralytic squint

Visual acuity.

Without glasses With glasses
Generic textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric text
Right eye
Left eye
If acuity not measured please state reason
Generic text
Eye defects not noted above:
Generic text

LATERALITY

Eye Dominance.
1
Uses right eye
2
Uses left eye
3
Uses either
0
Will not co-operate
Handedness. Which hand does this child use to write or draw with?
1
Right hand
2
Left hand
3
Either hand
Footedness. Which foot does this child use to kick a ball?
1
Right foot
2
Left foot
3
Either foot
Remarks on other abnormalities or deformities not reported above
Generic text
Pulse rate at end of examination. ... per minute.
How many

ASSESSMENTS

Alertness and activity.
2
Average
3
Above average
1
Below average
0
Apathetic
Physical development.
1
Average
2
Superior
0
Inferior

PARENTS' MEASUREMENTS

It would be of great value if the following information could be obtained about the parents of this child. It is realised that it may not be possible to get actual measurements in which case please give approximate figures.

Weight (in indoor clothes) ... st. Weight (in indoor clothes) ... lbs. Weight (in indoor clothes) * Height (deduct height of heels if measured in shoes) ... ft. Height (deduct height of heels if measured in shoes) ... ins. Height (deduct height of heels if measured in shoes) *

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

1 - actual

2 - estimate

StonesPounds in stoneFeetInches in foot

1 - actual

2 - estimate

Pounds in stoneInches in foot

1 - actual

2 - estimate

StonesFeetInches in footFeetPounds in stoneStones

1 - actual

2 - estimate

1 - actual

2 - estimate

Pounds in stone

1 - actual

2 - estimate

StonesInches in footFeet

1 - actual

2 - estimate

1 - actual

2 - estimate

Feet

1 - actual

2 - estimate

StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot

1 - actual

2 - estimate

1 - actual

2 - estimate

Mother
Father
Age of father ... years
Age
Estimate of the reliability of the medical history given by this mother.
1
Probably reliable
2
Probably unreliable
0
Undecided

CHECK OF PAST INFORMATION

THE FOLLOWING CONDITIONS WERE REPORTED IN EARLIER SURVEYS. PLEASE CHECK THEIR ACCURACY AND SUPPLY, IF POSSIBLE, THE ADDITIONAL INFORMATION ASKED FOR.

Condition Age when reported Additional information needed Doctor's comments
AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text
1
2
3
ALL QUESTIONS SHOULD BE ANSWERED (OR CROSSED OUT IF NOT APPLICABLE). PLEASE CHECK THAT THIS HAS BEEN DONE
Name of Doctor making Examination
Generic text
Date of Examination
Generic date
Time taken for this interview
Time taken
Name

1952 Examination by the School Doctor