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YOUTHSCAN U.K.
An Initiative of the International Centre for Child Studies
MEDICAL EXAMINATION FORM
STRICTLY CONFIDENTIAL
Director: Professor Neville Butler MD, FRCP, FRCOG, DCH International Centre for Child Studies
PLEASE USE BLOCK CAPITALS

Teenager's Surname

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Teenager's Forename(s)

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Sex

1
M
2
F

Teenager's Home Address

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Telephone Number

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Postcode

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Date of Birth

Date of birth

Health District

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Today's date

Generic date

Name of Examining Medical Officer:

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Status: e.g. SCMO, CMO, etc.

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INTRODUCTORY NOTES
May we take this opportunity to thank you for carrying out this examination on behalf of Youthscan UK.
For your assistance, a short instruction manual for health personnel is provided with this examination form. This includes an outline of the historical background of the Study, a near-vision test sheet and some procedural details.
You will need the following equipment for the medical examination:
PROCEDURE: EQUIPMENT RECOMMENDED:
Height: Steel/wooden measuring rod or steel tape measure. If not available, stadiometer on back of weighing machine should be used.
Weight: Beam balance, or other accurate apparatus. Please calibrate this to zero initially.
Head Circumference: Paper or plastic-covered tape measure.
Distant Vision: Standard Snellen Chart (or equivalent).
Near Vision: Near Vision card of Sheridan-Gardiner type, reproduced in instruction manual, by kind permission of the authors.
Blood Pressure: Mercury sphygmomanometer. Please use an adult-size cuff and not small cuff designed for children. The bladder within the cuff should be deep enough to cover about two-thirds of the length of upper arm and long enough to circle the arm completely.
Motor Co-ordination Tests: Tennis or rubber ball: a piece of chalk: stop-watch or a watch with second hand.
Audiogram: Audiometer for sweep audiogram. An audiogram form is provided on this form for recording result of sweep or pure-tone audiogram.
In addition, access to all the following will be needed for completion of medical examination form.
Completed Parental Interview Form: This will contain some medical and family details.
Health Records etc.: School medical record cards(s); any available screening records, assessment results, hospital reports, etc.; health file on any children with handicap or disability.
NOTE: IF ONE OR MORE OF THE ABOVE ITEMS IS NOT AVILABLE PLEASE COMPLETE THE MEDICAL EXAMINATION AS FAR AS POSSIBLE.
Introduction
Most, but not all, of the cohort and their parents have already participated in this Study, either in the perinatal period, intermediately, or at five or ten years.
At five and ten years, health visitors of your DHA caried out an extensive review of the health, development and pre-school care.
At ten years we were able, through your DHA, to identify members of the cohort who had health problems, disabilities and handicaps. Health Visitors and Community Medical Officers kindly conducted interviews and examinations.
Parents of the teenagers have this time received a letter explaining the 16 year Study, inviting their co-operation and ensuring them of confidentiality.
This time some of the mothers will already have been interviewed at home by a health visitor/school nurse; for the remainder, the home interview could be done subsequently, or accomplished at the same time as the medical examination provided that the mother agrees to attend at that time. The documents needed for the maternal interview consist of The Parental Interview Form (Document O), The Maternal Self-Completion Form (Document P) and The Teenage Leisure Diary (Document S). For the medical examination the following documents are needed (i) The Medical Examination Form (Document R), (ii) The Teenage Health Self-Completion Questionnaire, which should be completed by the teenager at the time of attendance for the medical examination (iii) The Information Manual for Health Personnel (Document N), includes the necessary instructions and contains a Sheridan-Gardiner Near Vision sheet for testing near vision.
Your Local Education Authority has kindly traced the whereabouts of the cohort in your DHA and has arranged a separate school educational assessment of each teenager, including tests of reading, vocabulary, mathematics, matrices and spelling; from this, it will be possible to identify slow learners and teenagers with educational as well as health problems.
THE MEDICAL EXAMINATION FORM IS IN THREE SECTIONS
Section 1. (A) Use of Service, (B) Disabilities ( pages 3 and 4)
In order to complete this section fully, you will need to assemble all the teenager's school medical records and all other relevant school health and educational documents. You are asked to pay particular attention to assembling complete records of any teenager who is handicapped, receiving special education, or who has been assessed for special educational needs. You will be asked to provide a summary from the notes of the progress and current status of each such teenager. Even if only partial records are accessible to you, please complete all Sections of this questionnaire as far as possible at the time of the medical examination.
Section 2. (A) Morbidity and Special Senses, (B) Medical Examination (pages 4-9)
Please make sure that the recommended equipment is available. Please read in advance if you have time, the medical history from the Parental Interview Form if already completed. Please read through the medical questions carefully before the examination. If you have time, please try out the co-ordination tests. The medical examination is structured to provide the maximum information while leaving you free to conduct the clinical examnation in any way you find optimal. Tests such as distant and near vision and measurements of height, weight, head circumference and blood pressure have been aggregated in the medical examination form, in case it proves expedient to carry these out just prior to the actual clinical examination. Please feel free to undertake the necessary measurements, in the order which best suits the facilities available to you and anyone helping you with the examination.
Section 3: Medical Summary. This is self-explanatory (pages 10 and 11)
Section 4: The Audiogram (page 12)
An Audiogram form is on the last sheet of the examination form. It is presumed that this will be done by sweep audiometry. The form also contains space in case pure-tone audiometry is used. You are asked to record whether the results of sweep audiometry are normal or abnormal and if sweep results are abnormal, to arrange to let us have details of pure-tone audiometry. In instance where sweep audiometry is impossible to arrange, or is delayed unavoidably,the remainder of completed health documents should be sent on to us in advance of the audiogram.
SECTION 1A. USE OF SERVICES

Where is this medical examination taking place?

1
School
2
Child Health Clinic
3
GP Surgery/Health Centre
4
Young person's home
5
Elsewhere Please specify
Other

Has this study teenager ever had school medical examination/developmental checks/vision or hearing tests)?

1
YES
2
NO
3
NOT KNOWN
If YES,
qc_A2 == 1

at what age(s) were procedures carried out Examinations

1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15

at what age(s) were procedures carried out Development Checks

1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15

at what age(s) were procedures carried out Vision Screenings

1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15

at what age(s) were procedures carried out Hearing Tests

1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15

at what age(s) were procedures carried out Other (What? ...)

1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15
Other
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

Is there any evidence that the study teenager has attended any of the following since 10 years old? Hearing clinic/consultant audiologist

1
Yes
2
No
3
Don't know
If YES,
qc_A4_a == 1

why?

Generic text

Is there any evidence that the study teenager has attended any of the following since 10 years old? Eye clinic/consultant ophthalmologist

1
Yes
2
No
3
Don't know
If YES,
qc_A4_b == 1

why?

Generic text

Is there any evidence that the study teenager has attended any of the following since 10 years old? Speech therapy

1
Yes
2
No
3
Don't know
If YES,
qc_A4_c == 1

why?

Generic text

Is there any evidence that the study teenager has attended any of the following since 10 years old? Physiotherapy

1
Yes
2
No
3
Don't know

Is there any evidence that the study teenager has attended any of the following since 10 years old? Child and Family Guidance Service

1
Yes
2
No
3
Don't know

Is there any evidence that the study teenager has attended any of the following since 10 years old? Other psychological or psychiatric opinion or treatment

1
Yes
2
No
3
Don't know
If YES,
qc_A4_d == 1 || qc_A4_e == 1 || qc_A4_f == 1

why

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Where does this study teenager live and what type of school does he/she attend?

1
At home and attends ordinary school
2
At home and attends special unit attached to ordinary school
3
At home and attends day special school
4
In a residential special school
5
In a hostel and attends day special school
6
In a hospital for the subnormal
7
In any other situation (What? ...)
Other
If attends other than ordinary school,
qc_A5 >= 3 && qc_A5 <= 7

please give name, address and designation of school institutions.

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Has a decision been reached by a local education authority that the teenager is in need of special education help/provision?

1
No, and not likely to be required
2
No, but likely to be required
3
No, but decision pending
4
Yes, waiting for a place
5
Yes, receiving special educational help
6
Yes, received special educational help in past, but no longer
7
Not known
If receiving/received special educational help, please answer 6(a) below.
qc_A6 >= 4 && qc_A6 <= 6

What help was given, why, when and what has been the result?

Generic text
SECTION 1B. DISABILITIES

Is there any evidence that the study teenager has had any emotional or behavioural problem since 10 years?

1
YES
2
NO
3
DON'T KNOW
If YES,
qc_B1 == 1

please describe problem(s) and give age(s) when occurred

Generic text

Is there any evidence that this teenager has now or has had in the past any significant illness, developmental problem, defect or handicap?

1
YES
2
NO
3
Insufficient information
If YES,
qc_B2 == 1
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
If the teenager has any disability or handicap for which he/she has had assessment for special educational help,

please summarise the major findings, clinical progress and present state, from records and all other sources.

Long text
(if necessary, please continue on page 11).
SECTION 2A. MORBIDITY AND SPECIAL SENSES

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?

1
YES, minimal: Unilateral
2
YES, minimal: Bilateral
3
YES, moderate: Unilateral
4
YES, moderate: Bilateral
5
YES, marked: Unilateral
6
YES, marked: Bilateral
7
NO
8
Uncertain
9
Not known
If YES, i.e. unilateral or bilateral loss, answer 1(a), 1(b) and 1(c) below
qc_C1 >= 1 && qc_C1 <= 6

What is the probable cause?

Generic text

Do you consider that the hearing loss will interfere with normal schooling or everyday functioning?

1
YES, severely
2
YES, somewhat
3
NO,
4
Unable to assess

Does the teenager wear a hearing aid?

1
YES
2
NO

How intelligible have you found the teenager's speech?

1
Fully intelligible
2
Almost all words are intelligible
3
Many words unintelligible
4
All, or nearly all, words unintelligible
5
Unable to assess (please give reason ...)
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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

Has this teenager ever had any of the following conditions? Mental or educational retardation (please specify ...)

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
Generic text

Has this teenager ever had any of the following conditions? Any other significant illness or disability (please specify (i) ... (ii) ... (iii) ...)

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
Other
Other 2
Other 3
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
If YES to any, please answer 4(a).
qc_C4_a-g == 1

If YES to any of above, please describe

Long text
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

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?

1
No visual defect
2
Visual defect - but no interference
3
Visual defect - with some interference
4
Visual defect - manages school books with difficulty
5
Visual defect - requires special school books/visual aids
6
Visual defect - vision insufficient for special books
7
Unable to assess (please give reason ...)
8
Not examined
Generic text
If visual defect,
qc_C7 >= 2 && qc_C7 <= 7

please describe below

Generic text
SECTION 2B. MEDICAL EXAMINATION
INITIAL PULSE RATE

Before starting the Medical Examination, please settle the teenager for 2 minutes and take the pulse (over 1 minute) whilst the teenager is sitting. Pulse rate ... beats in 1 minute

How many
HEIGHT
Recommended technique:
Please position the teenager upright against a flat wall or a door. Encourage him/her to stretch to full height, keeping heels on the floor. Heels and buttocks should be flush against wall or door. Place a hardboard/book on the teenager's head. Mark the position of the lower edge with a pencil and then measure the height from the ground with a wood or steel measuring rod or steel tape measure. Alternatively, use measuring device on the back of a weighing machine and observe precautions as above. NB. Remove shoes before height is measured.

Height in cm, to nearest 0.5 cm = ... cms.

Centimetres
If centimetre measure not available, please record height in feet and inches.
qc_D2_a == NULL

Height in feet and inches, to nearest 1/4 inch = ... feet ... inches

Feet
Inches in foot
HEAD CIRCUMFERENCE
Measure with a paper or plastic tape measure, fitted closely and horizontally around the head just above the eyebrows so as to obtain a maximum circumference.

Head circumferene in cm, to nearest 0.5 cm = ... cms. or = ... inches

Centimetres
Inches
WEIGHT (IN UNDERCLOTHES)
Please weigh on a beam balance, if possible. Please check that the balance is set at zero before weighing.

Weight in kilograms, to nearest 0.1 kg = ... kg.

Kilograms
If kilogram scale not available, please record in pounds and ounces to nearest 1/2 ounce.
qc_D24_a == NULL

Weight in pounds and ounces = ... pounds ... ounces

Pounds
Ounces in pound
BLOOD PRESSURE
Please postpone to later in examination if you feel teenager is nervous.
Sphygmomanometer cuff must have bladder long enough to encircle the arm completely and be wide enough to cover two-thirds of the length of the upper arm. The cuff should preferably be at least 5 inches deep.
It is realised that you will be experienced in taking blood pressures, but we ask you to follow the instructions closely for uniformity: -
Sit subject on chair in as relaxed a state as possible. Wrap the cuff around the right upper arm, placing the rubber tubes from the bladder posteriorly for ease of access to right antecubital fossa. Palpate the right radial pulse and inflate the cuff to about 30mm.Hg. above the disappearance of the pulse. Slowly deflate till the pulse reappears. Deflate the cuff.
Place the stethoscope in the antecubital fossa over the brachial artery, but not in contact with any part of the cuff. Rapidly inflate the cuff to about 30mm.Hg. above the systolic pressure and then deflate at a rate of 2-3mm.Hg. per second.
The appearance of faint clear tapping sounds for 2 consecutive beats should be recorded as the Systolic Pressure.
Continue to deflate the cuff and the sounds will soften or may become swishing, then sharper sounds will reappear. With continuing deflation, there will be a sudden muffling of sounds, which will become soft and blowing. This is Korotkoff's 4th sound and represents the Diastolic Pressure. Do not wait until the point of complete disappearance of sounds.

Systolic pressure - taken by auscultation ... mm.

How many

Diastolic pressure - taken by auscultation ... mm.

How many
NOW PLEASE MAKE A GENERAL AND SYSTEMIC EXAMINATION OF THE TEENAGER AND ANSWER QUESTIONS BELOW BASED ON YOUR FINDINGS.
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 text

1 - Not present

2 - Yes present

Generic text

1 - Not present

2 - Yes present

Generic text

1 - 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 text

1 - No

2 - Yes

Generic text

1 - No

2 - Yes

Generic text

1 - 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?

Is there any evidence that this teenager has any past or present congenital abnormality? (Include both major and minor abnormalities).

1
YES
2
NO
If YES,
qc_D8 == 1

please describe below:

Generic text

On clinical impression, which of the following terms do you consider to be the most accurate description of the teenager?

1
Grossly obese
2
Moderately obese
3
Normal build
4
Thin
5
Very thin
6
Not examined
E. MOTOR COORDINATION TESTS
The following four tests will identify a clumsy or inco-ordinate subject as far as this is possible on clinical examination. Such tests are non-specific and difficult to validate, but will be used in conjunction with other findings and the opinions of teachers and parents, recorded elsewhere. The results will inevitably be influenced by the effects of subject's skill and experience. At the end of the tests the examiner is asked to give a considered opinion as to the degree of clumsiness or inco-ordination.
Please test all Youthscan teenagers except those who are grossly handicapped or those who are incapable of understanding the test(s). In these instances, please enter the reason after question E4.
THROWING A BALL IN THE AIR
You will need a tennis ball, or a rubber ball of equivalent size and weight.
The important point about this test is to discover the subject's optimum performance. We would therefore be grateful if you would carry out the test in the following way:
Ask the subject to stand in a space so that he/she has room to move. Say 'I want you to show me if you can throw the ball up in the air and catch it'. Allow two or three initial attempts. If the subject fails to catch the ball, record the fact and do not proceed with the test.
If the subject can catch the ball, say 'Now throw the ball up in the air and clap your hands together once before you catch it'. Then repeat the procedure increasing the number of claps until the subject fails on two successive attempts. Record the greatest number of claps resulting in a successful catch.
If the greatest number of claps was 2 or more, ask him/her to repeat the test, catching with one hand only. Let him/her use preferred hand.

RESULT INITIAL THROW

1
Could not catch ball
2
Caught ball
If caught ball answer 1(a) and 1(b).
qc_E1 == 2

If caught ball successfully, please continue with test and record the maximum number of claps achieved before catching with two hands ... claps

How many
If caught ball after at least 2 claps,
qc_E1_a >= '2'

please continue test catching the ball with the preferred hand, and record the maximum number of claps achieved before catching with preferred hand ... claps

How many
FIGURE DRAWING ON PALM OF HAND: (GRAPHESTHESIA)
You will need a blunt point, for example a biro with tip retracted.
Ask the subject to place both his/her hands on a table, palms uppermost. Using the blunt point, firmly describe a figure 8 on the subject's right palm. Take two seconds to draw it, and allow the subject to watch. Ask him/her what you have drawn.
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)
Please make sure the subject has no shoes on.
Ask the subject to stand on his/her right leg with the left foot against the knee of the right leg, hands on hips. Ask him/her to settle for a moment, then to keep the position for 30 seconds.
Watch the position of hands and feet and record how soon the hands move from the hips or the feet move. Repeat the test with subject standing on the left leg, and time in same way.

Right leg: 30 seconds Did foot/feet move before 30 seconds?

1
No
2
Yes
If YES,
qc_E3_a_i == 2

after how many seconds? ... secs

How many

Right leg: 30 seconds Did hand(s) move before 30 seconds?

1
No
2
Yes
If YES,
qc_E3_b_i == 2

after how many seconds? ... secs

How many

Left leg: 30 seconds Did foot/feet move before 30 seconds?

1
No
2
Yes
If YES,
qc_E3_a_ii == 2

after how many seconds? ... secs

How many

Left leg: 30 seconds Did hand(s) move before 30 seconds?

1
No
2
Yes
If YES,
qc_E3_b_ii == 2

after how many seconds? ... secs

How many

Comments, if any:

Generic text
WALKING BACKWARDS (10 STEPS)
Please make sure the subject has no shoes on.
Find a straight line on the floor at least 4 metres long, e.g. the groove of a floorboard, or mark one out with chalk. Use a corridor if the examination room is not long enough.
Ask the subject to put his/her hands on hips and then to walk backwards along the line, placing one foot behind the other, toe-to-heel.
First demonstrate the test, saying 'I want you to walk like this. Remember your toes must touch your heel with each step you take. Keep your hands on your hips. Walk backwards in a straight line. You may glance behind you if it helps'.
Let the subject have two practices by asking him/her to walk backwards for 5 steps on each occasion.
Then ask the subject to walk backwards for 20 steps. Count the number of steps made before any error occurs. An error occurs if the subject ceases to maintain toe-to heel or deviates from the line or moves either hand from hips. If an error is made in the first 5 steps, continue to count the number of steps until the next error.

RESULT Number of consecutive steps taken before error (or between an error in the first 5 steps and the next error) ... steps

How many

Comments, if any:

Generic text
If these tests are not done,

give reason

Generic text

From your observations, which of the following phrases do you consider best describes the teenager?

1
Normal limb co-ordination
2
Questionably clumsy
3
Mildly clumsy
4
Moderately clumsy
5
Markedly clumsy
6
Unable to assess
PULSE RATE AT END OF EXAMINATION

Would you please settle the teenager and after at least 2 minutes take the teenager's pulse rate again for at least 60 seconds, with the teenager sitting. Pulse rate at end of examination ... beats in 1 minute

How many
MEDICAL SUMMARY
SUMMARY OF CONDITIONS FOUND AND CONCLUSIONS

Have you found any evidence by examination or from history that this teenaer had/has any impairment, disability or handicap? Please include also educational and social problems/difficulties.

1
YES
2
NO
3
DON'T KNOW
If YES, please answer 1(a) below.
qc_F1 == 1
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 text

1 - 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 text

1 - 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

Has your medical examination and scrutiny of the teenager's documents revealed the presence of any abnormal condition(s) or symptom(s) which have not previously been diagnosed or are not already under observation?

1
YES
2
NO
3
DON'T KNOW
If YES, please answer 2(a) below.
qc_F2 == 1

Please list each problem/condition not previously diagnosed or not already under observation.

Generic text
Generic text 2
Generic text 3

Do you consider that this teenager has any condition(s) requiring ongoing medical observation or treatment for any reason?

1
2
3
4
If YES, please answer 3(a) below.
qc_F3 == 2 || qc_F3 == 3

Please state condition(s) and give your recommendation(s) regarding necessary ongoing observation(s) or treatment for each condition.

Long text
Long text 2
Long text 3

ENTER IN THIS SPACE DETAILS OF CLINICAL PROGRESS AND MAJOR FINDINGS ON ANY DEFECT, DISABILITY OR HANDICAPPING CONDITION(S).

Long text

PLEASE ADD HERE FURTHER ANSWER(S) TO ANY QUESTIONS WHERE THERE WAS INSUFFICIENT SPACE ON THIS FORM.

Long text

SPACE FOR ANY COMENTS BY SCM (CHILD HEALTH) OR PERSON WHO ACTS AS CENTRAL STUDY CO-ORDINATOR

Long text
Before signing the form would you please check that ALL QUESTIONS have been answered and suitably recorded.

Date

Generic date
THANK YOU VERY MUCH FOR YOUR HELP.
SECTION 4. AUDIOGRAM

Teenager's Surname

Generic text

Sex

1
M
2
F

Teenager's Forename(s)

Generic text

Date of birth

Date of birth

Teenager's Home Address

Generic text
Please check the teenager's hearing by using either sweep audiometry or pure-tone audiometry, and record the results below.

SWEEP AUDIOMETRY Right ear

1
Normal
2
Abnormal
If Abnormal to question s4ai
qc_s4_a_i == 2

Give reason

Generic text

SWEEP AUDIOMETRY Left ear

1
Normal
2
Abnormal
If Abnormal to question s4aii
qc_s4_a_ii == 2

Give reason

Generic text
If you are satisfied that the teenager has abnormal or possibly abnormal hearing, please undertake pure-tone audiometry and record the results below.
qc_s4_a_i == 2 || qc_s4_a_ii == 2
PURE-TONE AUDIOMETRY RIGHT EAR
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-10
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PURE-TONE AUDIOMETRY LEFT EAR
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Please complete the details below for sweep audiometry, and for pure-tone audiometry if done.

Audiogram recorded at

Generic text

Name of recorder

Generic text

Date

Generic date

Professional status

Generic text

Make of audiometer

Generic text

Level of sweep ... dB's

How many

Frequencies tested by sweep

How many
How many 2
How many 3
NOTE CAREFULLY
*If it is impossible to arrange for audiometry to be carried out for this survey,
qc_s4_vi == NULL

please enter date and result of most recent audiogram below, whether sweep or pure-tone. Alternatively, give result of recent clinical assessment, if any. Type of test

Generic text

please enter date and result of most recent audiogram below, whether sweep or pure-tone. Alternatively, give result of recent clinical assessment, if any. Result

Generic text

please enter date and result of most recent audiogram below, whether sweep or pure-tone. Alternatively, give result of recent clinical assessment, if any. Date tested

Generic date
End

bcs_86_me

YOUTHSCAN U.K.
An Initiative of the International Centre for Child Studies
MEDICAL EXAMINATION FORM
STRICTLY CONFIDENTIAL
Director: Professor Neville Butler MD, FRCP, FRCOG, DCH International Centre for Child Studies
PLEASE USE BLOCK CAPITALS
Teenager's Surname
Generic text
Teenager's Forename(s)
Generic text
Sex
1
M
2
F
Teenager's Home Address
Generic text
Telephone Number
Generic text
Postcode
Generic text
Date of Birth
Date of birth
Health District
Generic text
Today's date
Generic date
Name of Examining Medical Officer:
Generic text
Status: e.g. SCMO, CMO, etc.
Generic text
INTRODUCTORY NOTES
May we take this opportunity to thank you for carrying out this examination on behalf of Youthscan UK.
For your assistance, a short instruction manual for health personnel is provided with this examination form. This includes an outline of the historical background of the Study, a near-vision test sheet and some procedural details.
You will need the following equipment for the medical examination:
PROCEDURE: EQUIPMENT RECOMMENDED:
Height: Steel/wooden measuring rod or steel tape measure. If not available, stadiometer on back of weighing machine should be used.
Weight: Beam balance, or other accurate apparatus. Please calibrate this to zero initially.
Head Circumference: Paper or plastic-covered tape measure.
Distant Vision: Standard Snellen Chart (or equivalent).
Near Vision: Near Vision card of Sheridan-Gardiner type, reproduced in instruction manual, by kind permission of the authors.
Blood Pressure: Mercury sphygmomanometer. Please use an adult-size cuff and not small cuff designed for children. The bladder within the cuff should be deep enough to cover about two-thirds of the length of upper arm and long enough to circle the arm completely.
Motor Co-ordination Tests: Tennis or rubber ball: a piece of chalk: stop-watch or a watch with second hand.
Audiogram: Audiometer for sweep audiogram. An audiogram form is provided on this form for recording result of sweep or pure-tone audiogram.
In addition, access to all the following will be needed for completion of medical examination form.
Completed Parental Interview Form: This will contain some medical and family details.
Health Records etc.: School medical record cards(s); any available screening records, assessment results, hospital reports, etc.; health file on any children with handicap or disability.
NOTE: IF ONE OR MORE OF THE ABOVE ITEMS IS NOT AVILABLE PLEASE COMPLETE THE MEDICAL EXAMINATION AS FAR AS POSSIBLE.
Introduction
Most, but not all, of the cohort and their parents have already participated in this Study, either in the perinatal period, intermediately, or at five or ten years.
At five and ten years, health visitors of your DHA caried out an extensive review of the health, development and pre-school care.
At ten years we were able, through your DHA, to identify members of the cohort who had health problems, disabilities and handicaps. Health Visitors and Community Medical Officers kindly conducted interviews and examinations.
Parents of the teenagers have this time received a letter explaining the 16 year Study, inviting their co-operation and ensuring them of confidentiality.
This time some of the mothers will already have been interviewed at home by a health visitor/school nurse; for the remainder, the home interview could be done subsequently, or accomplished at the same time as the medical examination provided that the mother agrees to attend at that time. The documents needed for the maternal interview consist of The Parental Interview Form (Document O), The Maternal Self-Completion Form (Document P) and The Teenage Leisure Diary (Document S). For the medical examination the following documents are needed (i) The Medical Examination Form (Document R), (ii) The Teenage Health Self-Completion Questionnaire, which should be completed by the teenager at the time of attendance for the medical examination (iii) The Information Manual for Health Personnel (Document N), includes the necessary instructions and contains a Sheridan-Gardiner Near Vision sheet for testing near vision.
Your Local Education Authority has kindly traced the whereabouts of the cohort in your DHA and has arranged a separate school educational assessment of each teenager, including tests of reading, vocabulary, mathematics, matrices and spelling; from this, it will be possible to identify slow learners and teenagers with educational as well as health problems.
THE MEDICAL EXAMINATION FORM IS IN THREE SECTIONS
Section 1. (A) Use of Service, (B) Disabilities ( pages 3 and 4)
In order to complete this section fully, you will need to assemble all the teenager's school medical records and all other relevant school health and educational documents. You are asked to pay particular attention to assembling complete records of any teenager who is handicapped, receiving special education, or who has been assessed for special educational needs. You will be asked to provide a summary from the notes of the progress and current status of each such teenager. Even if only partial records are accessible to you, please complete all Sections of this questionnaire as far as possible at the time of the medical examination.
Section 2. (A) Morbidity and Special Senses, (B) Medical Examination (pages 4-9)
Please make sure that the recommended equipment is available. Please read in advance if you have time, the medical history from the Parental Interview Form if already completed. Please read through the medical questions carefully before the examination. If you have time, please try out the co-ordination tests. The medical examination is structured to provide the maximum information while leaving you free to conduct the clinical examnation in any way you find optimal. Tests such as distant and near vision and measurements of height, weight, head circumference and blood pressure have been aggregated in the medical examination form, in case it proves expedient to carry these out just prior to the actual clinical examination. Please feel free to undertake the necessary measurements, in the order which best suits the facilities available to you and anyone helping you with the examination.
Section 3: Medical Summary. This is self-explanatory (pages 10 and 11)
Section 4: The Audiogram (page 12)
An Audiogram form is on the last sheet of the examination form. It is presumed that this will be done by sweep audiometry. The form also contains space in case pure-tone audiometry is used. You are asked to record whether the results of sweep audiometry are normal or abnormal and if sweep results are abnormal, to arrange to let us have details of pure-tone audiometry. In instance where sweep audiometry is impossible to arrange, or is delayed unavoidably,the remainder of completed health documents should be sent on to us in advance of the audiogram.

SECTION 1A. USE OF SERVICES

Where is this medical examination taking place?
1
School
2
Child Health Clinic
3
GP Surgery/Health Centre
4
Young person's home
5
Elsewhere Please specify
Other
Has this study teenager ever had school medical examination/developmental checks/vision or hearing tests)?
1
YES
2
NO
3
NOT KNOWN
at what age(s) were procedures carried out Examinations
1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15
at what age(s) were procedures carried out Development Checks
1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15
at what age(s) were procedures carried out Vision Screenings
1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15
at what age(s) were procedures carried out Hearing Tests
1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15
at what age(s) were procedures carried out Other (What? ...)
1
5
2
6
3
7
4
8
5
9
6
10
7
11
8
12
9
13
10
14
11
15
Other

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
Is there any evidence that the study teenager has attended any of the following since 10 years old? Hearing clinic/consultant audiologist
1
Yes
2
No
3
Don't know
why?
Generic text
Is there any evidence that the study teenager has attended any of the following since 10 years old? Eye clinic/consultant ophthalmologist
1
Yes
2
No
3
Don't know
why?
Generic text
Is there any evidence that the study teenager has attended any of the following since 10 years old? Speech therapy
1
Yes
2
No
3
Don't know
why?
Generic text
Is there any evidence that the study teenager has attended any of the following since 10 years old? Physiotherapy
1
Yes
2
No
3
Don't know
Is there any evidence that the study teenager has attended any of the following since 10 years old? Child and Family Guidance Service
1
Yes
2
No
3
Don't know
Is there any evidence that the study teenager has attended any of the following since 10 years old? Other psychological or psychiatric opinion or treatment
1
Yes
2
No
3
Don't know
why
Generic text
Where does this study teenager live and what type of school does he/she attend?
1
At home and attends ordinary school
2
At home and attends special unit attached to ordinary school
3
At home and attends day special school
4
In a residential special school
5
In a hostel and attends day special school
6
In a hospital for the subnormal
7
In any other situation (What? ...)
Other
please give name, address and designation of school institutions.
Generic text
Has a decision been reached by a local education authority that the teenager is in need of special education help/provision?
1
No, and not likely to be required
2
No, but likely to be required
3
No, but decision pending
4
Yes, waiting for a place
5
Yes, receiving special educational help
6
Yes, received special educational help in past, but no longer
7
Not known
What help was given, why, when and what has been the result?
Generic text

SECTION 1B. DISABILITIES

Is there any evidence that the study teenager has had any emotional or behavioural problem since 10 years?
1
YES
2
NO
3
DON'T KNOW
please describe problem(s) and give age(s) when occurred
Generic text
Is there any evidence that this teenager has now or has had in the past any significant illness, developmental problem, defect or handicap?
1
YES
2
NO
3
Insufficient information

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
please summarise the major findings, clinical progress and present state, from records and all other sources.
Long text
(if necessary, please continue on page 11).

SECTION 2A. MORBIDITY AND SPECIAL SENSES

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?
1
YES, minimal: Unilateral
2
YES, minimal: Bilateral
3
YES, moderate: Unilateral
4
YES, moderate: Bilateral
5
YES, marked: Unilateral
6
YES, marked: Bilateral
7
NO
8
Uncertain
9
Not known
What is the probable cause?
Generic text
Do you consider that the hearing loss will interfere with normal schooling or everyday functioning?
1
YES, severely
2
YES, somewhat
3
NO,
4
Unable to assess
Does the teenager wear a hearing aid?
1
YES
2
NO
How intelligible have you found the teenager's speech?
1
Fully intelligible
2
Almost all words are intelligible
3
Many words unintelligible
4
All, or nearly all, words unintelligible
5
Unable to assess (please give reason ...)
Generic text

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
Has this teenager ever had any of the following conditions? Mental or educational retardation (please specify ...)
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
Generic text
Has this teenager ever had any of the following conditions? Any other significant illness or disability (please specify (i) ... (ii) ... (iii) ...)
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
Other
Other 2
Other 3

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
If YES to any of above, please describe
Long text

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
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?
1
No visual defect
2
Visual defect - but no interference
3
Visual defect - with some interference
4
Visual defect - manages school books with difficulty
5
Visual defect - requires special school books/visual aids
6
Visual defect - vision insufficient for special books
7
Unable to assess (please give reason ...)
8
Not examined
Generic text
please describe below
Generic text

SECTION 2B. MEDICAL EXAMINATION

INITIAL PULSE RATE

Before starting the Medical Examination, please settle the teenager for 2 minutes and take the pulse (over 1 minute) whilst the teenager is sitting. Pulse rate ... beats in 1 minute
How many

HEIGHT

Recommended technique:
Please position the teenager upright against a flat wall or a door. Encourage him/her to stretch to full height, keeping heels on the floor. Heels and buttocks should be flush against wall or door. Place a hardboard/book on the teenager's head. Mark the position of the lower edge with a pencil and then measure the height from the ground with a wood or steel measuring rod or steel tape measure. Alternatively, use measuring device on the back of a weighing machine and observe precautions as above. NB. Remove shoes before height is measured.
Height in cm, to nearest 0.5 cm = ... cms.
Centimetres
Height in feet and inches, to nearest 1/4 inch = ... feet ... inches
Feet
Inches in foot

HEAD CIRCUMFERENCE

Measure with a paper or plastic tape measure, fitted closely and horizontally around the head just above the eyebrows so as to obtain a maximum circumference.
Head circumferene in cm, to nearest 0.5 cm = ... cms. or = ... inches
Centimetres
Inches

WEIGHT (IN UNDERCLOTHES)

Please weigh on a beam balance, if possible. Please check that the balance is set at zero before weighing.
Weight in kilograms, to nearest 0.1 kg = ... kg.
Kilograms
Weight in pounds and ounces = ... pounds ... ounces
Pounds
Ounces in pound

BLOOD PRESSURE

Please postpone to later in examination if you feel teenager is nervous.
Sphygmomanometer cuff must have bladder long enough to encircle the arm completely and be wide enough to cover two-thirds of the length of the upper arm. The cuff should preferably be at least 5 inches deep.
It is realised that you will be experienced in taking blood pressures, but we ask you to follow the instructions closely for uniformity: -
Sit subject on chair in as relaxed a state as possible. Wrap the cuff around the right upper arm, placing the rubber tubes from the bladder posteriorly for ease of access to right antecubital fossa. Palpate the right radial pulse and inflate the cuff to about 30mm.Hg. above the disappearance of the pulse. Slowly deflate till the pulse reappears. Deflate the cuff.
Place the stethoscope in the antecubital fossa over the brachial artery, but not in contact with any part of the cuff. Rapidly inflate the cuff to about 30mm.Hg. above the systolic pressure and then deflate at a rate of 2-3mm.Hg. per second.
The appearance of faint clear tapping sounds for 2 consecutive beats should be recorded as the Systolic Pressure.
Continue to deflate the cuff and the sounds will soften or may become swishing, then sharper sounds will reappear. With continuing deflation, there will be a sudden muffling of sounds, which will become soft and blowing. This is Korotkoff's 4th sound and represents the Diastolic Pressure. Do not wait until the point of complete disappearance of sounds.
Systolic pressure - taken by auscultation ... mm.
How many
Diastolic pressure - taken by auscultation ... mm.
How many
NOW PLEASE MAKE A GENERAL AND SYSTEMIC EXAMINATION OF THE TEENAGER AND ANSWER QUESTIONS BELOW BASED ON YOUR FINDINGS.

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 text

1 - Not present

2 - Yes present

Generic text

1 - Not present

2 - Yes present

Generic text

1 - 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 text

1 - No

2 - Yes

Generic text

1 - No

2 - Yes

Generic text

1 - 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?
Is there any evidence that this teenager has any past or present congenital abnormality? (Include both major and minor abnormalities).
1
YES
2
NO
please describe below:
Generic text
On clinical impression, which of the following terms do you consider to be the most accurate description of the teenager?
1
Grossly obese
2
Moderately obese
3
Normal build
4
Thin
5
Very thin
6
Not examined

E. MOTOR COORDINATION TESTS

The following four tests will identify a clumsy or inco-ordinate subject as far as this is possible on clinical examination. Such tests are non-specific and difficult to validate, but will be used in conjunction with other findings and the opinions of teachers and parents, recorded elsewhere. The results will inevitably be influenced by the effects of subject's skill and experience. At the end of the tests the examiner is asked to give a considered opinion as to the degree of clumsiness or inco-ordination.
Please test all Youthscan teenagers except those who are grossly handicapped or those who are incapable of understanding the test(s). In these instances, please enter the reason after question E4.

THROWING A BALL IN THE AIR

You will need a tennis ball, or a rubber ball of equivalent size and weight.
The important point about this test is to discover the subject's optimum performance. We would therefore be grateful if you would carry out the test in the following way:
Ask the subject to stand in a space so that he/she has room to move. Say 'I want you to show me if you can throw the ball up in the air and catch it'. Allow two or three initial attempts. If the subject fails to catch the ball, record the fact and do not proceed with the test.
If the subject can catch the ball, say 'Now throw the ball up in the air and clap your hands together once before you catch it'. Then repeat the procedure increasing the number of claps until the subject fails on two successive attempts. Record the greatest number of claps resulting in a successful catch.
If the greatest number of claps was 2 or more, ask him/her to repeat the test, catching with one hand only. Let him/her use preferred hand.
RESULT INITIAL THROW
1
Could not catch ball
2
Caught ball
If caught ball successfully, please continue with test and record the maximum number of claps achieved before catching with two hands ... claps
How many
please continue test catching the ball with the preferred hand, and record the maximum number of claps achieved before catching with preferred hand ... claps
How many

FIGURE DRAWING ON PALM OF HAND: (GRAPHESTHESIA)

You will need a blunt point, for example a biro with tip retracted.
Ask the subject to place both his/her hands on a table, palms uppermost. Using the blunt point, firmly describe a figure 8 on the subject's right palm. Take two seconds to draw it, and allow the subject to watch. Ask him/her what you have drawn.

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)

Please make sure the subject has no shoes on.
Ask the subject to stand on his/her right leg with the left foot against the knee of the right leg, hands on hips. Ask him/her to settle for a moment, then to keep the position for 30 seconds.
Watch the position of hands and feet and record how soon the hands move from the hips or the feet move. Repeat the test with subject standing on the left leg, and time in same way.
Right leg: 30 seconds Did foot/feet move before 30 seconds?
1
No
2
Yes
after how many seconds? ... secs
How many
Right leg: 30 seconds Did hand(s) move before 30 seconds?
1
No
2
Yes
after how many seconds? ... secs
How many
Left leg: 30 seconds Did foot/feet move before 30 seconds?
1
No
2
Yes
after how many seconds? ... secs
How many
Left leg: 30 seconds Did hand(s) move before 30 seconds?
1
No
2
Yes
after how many seconds? ... secs
How many
Comments, if any:
Generic text

WALKING BACKWARDS (10 STEPS)

Please make sure the subject has no shoes on.
Find a straight line on the floor at least 4 metres long, e.g. the groove of a floorboard, or mark one out with chalk. Use a corridor if the examination room is not long enough.
Ask the subject to put his/her hands on hips and then to walk backwards along the line, placing one foot behind the other, toe-to-heel.
First demonstrate the test, saying 'I want you to walk like this. Remember your toes must touch your heel with each step you take. Keep your hands on your hips. Walk backwards in a straight line. You may glance behind you if it helps'.
Let the subject have two practices by asking him/her to walk backwards for 5 steps on each occasion.
Then ask the subject to walk backwards for 20 steps. Count the number of steps made before any error occurs. An error occurs if the subject ceases to maintain toe-to heel or deviates from the line or moves either hand from hips. If an error is made in the first 5 steps, continue to count the number of steps until the next error.
RESULT Number of consecutive steps taken before error (or between an error in the first 5 steps and the next error) ... steps
How many
Comments, if any:
Generic text
give reason
Generic text
From your observations, which of the following phrases do you consider best describes the teenager?
1
Normal limb co-ordination
2
Questionably clumsy
3
Mildly clumsy
4
Moderately clumsy
5
Markedly clumsy
6
Unable to assess

PULSE RATE AT END OF EXAMINATION

Would you please settle the teenager and after at least 2 minutes take the teenager's pulse rate again for at least 60 seconds, with the teenager sitting. Pulse rate at end of examination ... beats in 1 minute
How many

MEDICAL SUMMARY

SUMMARY OF CONDITIONS FOUND AND CONCLUSIONS
Have you found any evidence by examination or from history that this teenaer had/has any impairment, disability or handicap? Please include also educational and social problems/difficulties.
1
YES
2
NO
3
DON'T KNOW

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 text

1 - 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 text

1 - 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
Has your medical examination and scrutiny of the teenager's documents revealed the presence of any abnormal condition(s) or symptom(s) which have not previously been diagnosed or are not already under observation?
1
YES
2
NO
3
DON'T KNOW
Please list each problem/condition not previously diagnosed or not already under observation.
Generic text
Generic text 2
Generic text 3
Do you consider that this teenager has any condition(s) requiring ongoing medical observation or treatment for any reason?
1
2
3
4
Please state condition(s) and give your recommendation(s) regarding necessary ongoing observation(s) or treatment for each condition.
Long text
Long text 2
Long text 3
ENTER IN THIS SPACE DETAILS OF CLINICAL PROGRESS AND MAJOR FINDINGS ON ANY DEFECT, DISABILITY OR HANDICAPPING CONDITION(S).
Long text
PLEASE ADD HERE FURTHER ANSWER(S) TO ANY QUESTIONS WHERE THERE WAS INSUFFICIENT SPACE ON THIS FORM.
Long text
SPACE FOR ANY COMENTS BY SCM (CHILD HEALTH) OR PERSON WHO ACTS AS CENTRAL STUDY CO-ORDINATOR
Long text
Before signing the form would you please check that ALL QUESTIONS have been answered and suitably recorded.
Date
Generic date
THANK YOU VERY MUCH FOR YOUR HELP.

SECTION 4. AUDIOGRAM

Teenager's Surname
Generic text
Sex
1
M
2
F
Teenager's Forename(s)
Generic text
Date of birth
Date of birth
Teenager's Home Address
Generic text
Please check the teenager's hearing by using either sweep audiometry or pure-tone audiometry, and record the results below.
SWEEP AUDIOMETRY Right ear
1
Normal
2
Abnormal
Give reason
Generic text
SWEEP AUDIOMETRY Left ear
1
Normal
2
Abnormal
Give reason
Generic text

PURE-TONE AUDIOMETRY RIGHT EAR

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1 - O

1 - O

1 - O

1 - O

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1 - O

1 - O

-10
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90+

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

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-10
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90+
Please complete the details below for sweep audiometry, and for pure-tone audiometry if done.
Audiogram recorded at
Generic text
Name of recorder
Generic text
Date
Generic date
Professional status
Generic text
Make of audiometer
Generic text
Level of sweep ... dB's
How many
Frequencies tested by sweep
How many
How many 2
How many 3
NOTE CAREFULLY
please enter date and result of most recent audiogram below, whether sweep or pure-tone. Alternatively, give result of recent clinical assessment, if any. Type of test
Generic text
please enter date and result of most recent audiogram below, whether sweep or pure-tone. Alternatively, give result of recent clinical assessment, if any. Result
Generic text
please enter date and result of most recent audiogram below, whether sweep or pure-tone. Alternatively, give result of recent clinical assessment, if any. Date tested
Generic date
Name

BCS70 Age 16 Medical Examination Form