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---|---|---|---|---|
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 | ||||
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5 |
Where does this study teenager live and what type of school does he/she attend?
Tick one box only
Has a decision been reached by a local education authority that the teenager is in need of special education help/provision?
Tick one box



In the light of your clinical examination and the records you have seen, do you consider that there is evidence of any current hearing loss?
Tick one box only
Answer (a)-(r) and tick all that apply on each line
- | |
---|---|
1 - Yes, in past 12 months 2 - Yes, previous to past 12 months 3 - Yes, but age not known 4 - No, never 5 - Not known |
|
Recurrent sore throats (3 or more in past year) | |
Middle ear infection/glue ear | |
Any hearing loss, perceptive or conductive | |
Eczema | |
Hay Fever | |
Asthma | |
Wheezy bronchitis | |
Bronchitis | |
Pneumonia | |
Pathological heart condition | |
Recurrent abdominal pain | |
Inguinal hernia | |
Urinary infection | |
Wet bed more than occasionally since 10 years of age | |
Wet pants in daytime more than occasionally since 10 years of age | |
Soiled pants at any time since 10 years of age |
Has this teenager ever had any of the following conditions? Any other significant illness or disability (please specify (i) ... (ii) ... (iii) ...)
Answer (a)-(r) and tick all that apply on each line
Tick each line (a) - (f), and tick one box on each line

DISTANT VISUAL ACUITY | |
---|---|
1 - 6 2 - 9 3 - 12 4 - 18 5 - 24 6 - 36 7 - 60 8 - Worse than 60 9 - Unable to test |
|
Crude distant vision without glasses (test all teenagers): Right eye | |
Crude distant vision without glasses (test all teenagers): Left eye | |
Distant vision, wearing glasses/contacts: Right eye | |
Distant vision, wearing glasses/contacts: Left eye |

In the light of your examination and the records you have seen, would you consider that there is any current visual defect, and does it result in interference with normal schooling or everyday functioning?
Tick one box only


















Answer (a)-(o) and tick one box per line
- | If present, describe signs. What is diagnosis? | |
---|---|---|
1 - Not present 2 - Yes present Generic text1 - Not present 2 - Yes present Generic text |
1 - Not present 2 - Yes present Generic text1 - Not present 2 - Yes present Generic text |
|
Abnormality of face or general disfiguration | ||
Skin abnormality | ||
Upper respiratory abnormality | ||
Abnormal respiratory signs/conditions | ||
Cardiovascular abnormality | ||
Gastrointestinal abnormality | ||
Urogenital tract abnormality | ||
Neurological abnormality | ||
Musculo-skeletal abnormality | ||
Endocrine abnormality | ||
Blood or lymphatic abnormality | ||
Behavioural or emotional problems | ||
Mental handicap | ||
Other abnormal condition(s) or syndrome(s) |
Answer (a)-(e) and tick one box on each line












Answer (a)-(h) and tick one box on each line.














Nature of problem/defect/handicap | - | |
---|---|---|
1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text |
1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text |
|
1 | ||
2 | ||
3 | ||
4 | ||
5 | ||
6 |
ENTER IN THIS SPACE DETAILS OF CLINICAL PROGRESS AND MAJOR FINDINGS ON ANY DEFECT, DISABILITY OR HANDICAPPING CONDITION(S).
See questions B2 & 3. Please also append here or send to us any available copies of relevant child health reports and/or special educational documents relating to such condition(s).




If carried out, please record results below for air conduction and bone conduction.
250 | 500 | 1000 | 2000 | 4000 | 8000 | |
---|---|---|---|---|---|---|
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
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If carried out, please record results below for air conduction and bone conduction.
250 | 500 | 1000 | 2000 | 4000 | 8000 | |
---|---|---|---|---|---|---|
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
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bcs_86_me
SECTION 1A. USE OF SERVICES
What screening or preventive procedures have been carried out since study teenager was 10 years old? (include tests, immunisations, screening, check ups)
Screening/Other Procedures | Reason | Venue | Age | |
---|---|---|---|---|
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 | ||||
4 | ||||
5 |
SECTION 1B. DISABILITIES
please list conditions in chronological order of appearance on records, starting with earliest illness, developmental problem or handicap diagnosed.
Diagnosis | Age first recorded | Disposal | |
---|---|---|---|
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 | |||
5 |
SECTION 2A. MORBIDITY AND SPECIAL SENSES
Has this teenager ever had any of the following conditions?
- | |
---|---|
1 - Yes, in past 12 months 2 - Yes, previous to past 12 months 3 - Yes, but age not known 4 - No, never 5 - Not known |
|
Recurrent sore throats (3 or more in past year) | |
Middle ear infection/glue ear | |
Any hearing loss, perceptive or conductive | |
Eczema | |
Hay Fever | |
Asthma | |
Wheezy bronchitis | |
Bronchitis | |
Pneumonia | |
Pathological heart condition | |
Recurrent abdominal pain | |
Inguinal hernia | |
Urinary infection | |
Wet bed more than occasionally since 10 years of age | |
Wet pants in daytime more than occasionally since 10 years of age | |
Soiled pants at any time since 10 years of age |
In your opinion is there any evidence of any of the following psychological/psychiatric problems?
- | |
---|---|
1 - No 2 - Yes 3 - Don't Know |
|
Maladjustment/behaviour disturbance | |
Depression | |
Aggression | |
Appetite problems (e.g. Anorexia, Bulimia etc.) | |
Psychosis | |
Neurosis | |
Suicide attempt(s) /threats |
DISTANT VISION TEST
Test at exactly 20 feet with a standard Snellen Chart of block capitals. Hang chart in good light level with teenager's eyes and free from glare. Occlude opposite eye in usual way. Test all teenagers (without glasses) first and record result separately for Right Eye and Left Eye. Then re-test only teenagers with glasses/lens, wearing them.
DISTANT VISUAL ACUITY | |
---|---|
1 - 6 2 - 9 3 - 12 4 - 18 5 - 24 6 - 36 7 - 60 8 - Worse than 60 9 - Unable to test |
|
Crude distant vision without glasses (test all teenagers): Right eye | |
Crude distant vision without glasses (test all teenagers): Left eye | |
Distant vision, wearing glasses/contacts: Right eye | |
Distant vision, wearing glasses/contacts: Left eye |
NEAR-VISION TEST
A Sheridan-Gardiner near-vision chart is provided in the instruction manual. The teenager should hold it in a good light at a distance of approximately 10 inches away from the eyes. Please occlude the other eye efficiently without pressure on the eyeball. If the teenager cannot read, ask him/her to draw the letters in the air. Test near vision in all teenagers and then retest only teenagers with glasses/lenses, wearing them.
- | |
---|---|
1 - 6 2 - 9 3 - 12 4 - 18 5 - 24 6 - 36 7 - 60 8 - Worse than 60 9 - Unable to test |
|
Near Vision without glasses (all teenagers): Right eye | |
Near Vision without glasses (all teenagers): Left eye | |
Near Vision wearing glasses/contacts: Right eye | |
Near Vision wearing glasses/contacts: Left eye |
SECTION 2B. MEDICAL EXAMINATION
INITIAL PULSE RATE
HEIGHT
HEAD CIRCUMFERENCE
WEIGHT (IN UNDERCLOTHES)
BLOOD PRESSURE
Please state whether or not any abnormal condition has been found in any of the following systems in the teenager.
- | If present, describe signs. What is diagnosis? | |
---|---|---|
1 - Not present 2 - Yes present Generic text1 - Not present 2 - Yes present Generic text |
1 - Not present 2 - Yes present Generic text1 - Not present 2 - Yes present Generic text |
|
Abnormality of face or general disfiguration | ||
Skin abnormality | ||
Upper respiratory abnormality | ||
Abnormal respiratory signs/conditions | ||
Cardiovascular abnormality | ||
Gastrointestinal abnormality | ||
Urogenital tract abnormality | ||
Neurological abnormality | ||
Musculo-skeletal abnormality | ||
Endocrine abnormality | ||
Blood or lymphatic abnormality | ||
Behavioural or emotional problems | ||
Mental handicap | ||
Other abnormal condition(s) or syndrome(s) |
Did your examination reveal any of the following?
- | If YES, please describe: | |
---|---|---|
1 - No 2 - Yes Generic text1 - No 2 - Yes Generic text |
1 - No 2 - Yes Generic text1 - No 2 - Yes Generic text |
|
Any scars (surgical, burns, etc.)? | ||
Any hernia? | ||
Any heart murmur? | ||
Undescended/ectopic testis? | ||
Any other abnormality not already stated in question D6? |
E. MOTOR COORDINATION TESTS
THROWING A BALL IN THE AIR
FIGURE DRAWING ON PALM OF HAND: (GRAPHESTHESIA)
Now please show the subject the 4 figures reproduced above, and ask the subject to name each one. Ask subject to close his/her eyes. Draw the first figure indicated in the following list on the right palm and ask what it was. Record whether correct, incorrect or uncertain. Continue drawing the figures on the palm indicated and record the results. Please do not repeat any part of the test.If the subject is non-verbal, ask him/her to point to the correct shape rather than name it.NOTE: DO NOT LET THE SUBJECT SEE THIS SCORE SHEET
- | |
---|---|
1 - Response correct 2 - Response incorrect 3 - Response uncertain |
|
Right palm (Figures) □ | |
Left palm (Figures) X | |
Right palm (Figures) O | |
Left palm (Figures) □ | |
Right palm (Figures) 3 | |
Left palm (Figures) O | |
Right palm (Figures) X | |
Left palm (Figures) 3 |
STANDING ON ONE LEG: (30 SECONDS)
WALKING BACKWARDS (10 STEPS)
PULSE RATE AT END OF EXAMINATION
MEDICAL SUMMARY
List each condition below and assess the effect, if any, on the teenagers home or school progress.
Nature of problem/defect/handicap | - | |
---|---|---|
1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text |
1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text1 - Condition present but no real disability 2 - Condition resulting in slight disability 3 - Condition resulting in marked disability Generic text |
|
1 | ||
2 | ||
3 | ||
4 | ||
5 | ||
6 |
SECTION 4. AUDIOGRAM
PURE-TONE AUDIOMETRY RIGHT EAR
250 | 500 | 1000 | 2000 | 4000 | 8000 | |
---|---|---|---|---|---|---|
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O 1 - O |
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PURE-TONE AUDIOMETRY LEFT EAR
250 | 500 | 1000 | 2000 | 4000 | 8000 | |
---|---|---|---|---|---|---|
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X 1 - X |
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BCS70 Age 16 Medical Examination Form