Start
ncds_69_mq
STRICTLY CONFIDENTIAL

Local Authority code number

Local Authority Code number

Child's Code number

Child's Code number
MEDICAL EXAMINATION FORM*
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
SPONSORED AND ADMINISTERED BY: National Bureau for Co-operation in Child Care
CO-SPONSORED BY:
Institute of Child Health, University of London
National Birthday Trust Fund
National Foundation for Educational Research in England and Wales
IN COLLABORATION WITH:
ENGLAND AND WALES
Association of Chief Education Officers
Society of Medical Officers of Health
SCOTLAND
Association of Directors of Education
Association of School Medical and Dental Officers
CHAIRMAN OF CONSULTATIVE COMMITTEE:
Mary D. Sheridan, O.B.E., M.A., M.D., D.C.H.
CHAIRMAN OF STEERING COMMITTEE: W.D. Wall, B.A., PH.D.
EXECUTIVE CO-DIRECTORS:
Professor N. R. Butler, M.D., F.R.C.P., D.C.H.
Mrs. M. L. Kellmer Pringle, B.A., PH.D., DIP. ED. PSYCH.
CO-DIRECTOR AND PRINCIPAL INVESTIGATOR:
R. Davie, B.A., DIP.ED.PSYCH.
CO-DIRECTORS: M. J. R. Healy, B.A.
J. M. Tanner, M.D., D.SC , M.R.C.P.
W.D. Wall, B.A., PH.D.
SENIOR RESEARCH OFFICER:
P. J. Wedge, M.A., DIP.PUB.SOC.ADMIN., DIP.APP.SOC.STUD.

CHILD'S NAME (Surname)

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CHILD'S NAME (Christian Names)

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CHILD'S SEX (Please ring appropriate number)

1
Boy
2
Girl

TODAY'S DATE

Generic date

CHILD'S PRESENT HOME ADDRESS

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NAME OF MEDICAL EXAMINER (Block Capitals)

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IS CHILD ACCOMPANIED BY:

1
Mother
2
Other adult (specify)
3
No adult

CHILD'S DATE OF BIRTH

Date of birth
*Please read carefully the 'INTRODUCTORY NOTES AND INSTRUCTIONS FOR THE NATIONAL CHILD DEVELOPMENT STUDY (N.C.D.S.) 11 YEAR EXAMINATION' before completing the form.
Have you the following records at your disposal now or when completing this form?
-

1 - Yes

2 - No

Completed parental interview form
Infant Welfare Record
School Medical Record (Form 10M in England and Wales, School Medical Card in Scotland)

Has a decision been reached by the Local Authority that the child is in need of 'special educational treatment' or exclusion from school?

1
No, and not likely to be required
2
No, but a decision pending
3
Yes, but waiting for a place
4
Yes, and receiving special educational treatment
5
Don't know
If yes (or a decision is pending),
qc_9_a == 2 || qc_9_a == 3 || qc_9_a == 4

into which of the following categories does the child fall?

1
Blind
2
Partially sighted
3
Deaf
4
Partially hearing
5
Educationally subnormal
6
Severely subnormal
7
Epileptic
8
Maladjusted
9
Physically handicapped
X
Speech defect
Y
Delicate

Do you have access to special records relating to the handicapping condition, e.g. form 2HP, 4HP (MH3 in Scotland) in completing this form?

1
Yes
2
No
If Yes,
qc_9_c == 1

please list form(s) available

Generic text
MEDICAL HISTORY
Please amplify any relevant conditions in the following list, giving further details of diagnosis, age at diagnosis, action taken (e.g. operation, type of medical treatment, and place of treatment). When G.P. has treated, write simply 'G.P.' but for hospitals and non-G.P. clinics please give full name and address. Space for this is afforded on the right of the page.
VISION

Has child ever been found to have an abnormal eye condition (including squint)?

1
Never
2
Yes, transient complaint now recovered
3
Yes, permanent condition
4
Information insufficient
If Yes,
qc_10 == 2 || qc_10 == 3

state which eye

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Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Does child usually wear glasses?

1
No
2
Yes, for reading only
3
Yes, all the time
4
Information insufficient
5
Other (please specify)
Other
HEARING

Has the child ever had impaired hearing?

1
No
2
Yes, congenital condition
3
Yes, acquired condition (permanent)
4
Yes, acquired condition (transient)
5
Yes, cause uncertain
6
Information insufficient
If Yes,
qc_12 >= 2 && qc_12 <= 5

which ear

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Nature of severity of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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UPPER RESPIRATORY SYSTEM

Has child ever had any abnormality of the ear/nose/throat/palate (other than transient)? Do not include impaired hearing.

1
No
2
Yes
3
Information insufficient
If Yes,
qc_13 == 2

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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LOWER RESPIRATORY SYSTEM

Has the child ever had wheezy bronchitis or asthma (other than mild attacks in infancy)?

1
No
2
Yes, before seventh birthday
3
Yes, after seventh birthday
4
Yes, both before and after seventh birthday
5
Information insufficient
If Yes,
qc_14 == 2 || qc_14 == 3 || qc_14 == 4

Type of attacks

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Age at first attack (if known)

Age

Frequency at present

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Severity at present

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Degree of disability at present

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How treated, e.g. inhalers, steroids

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Place of investigation/treatment

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Has the child ever had a non-asthmatic chest complaint?

1
No
2
Yes
3
Information insufficient
If Yes,
qc_15 == 2

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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HEART

Has the child ever had any abnormal heart condition?

1
No
2
Yes, congenital disorder
3
Yes, acquired disorder
4
Information insufficient
If Yes,
qc_16 == 2 || qc_16 == 3

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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SKIN

Has the child ever had a recurrent skin complaint? Please ring all relevant codes.

1
No
2
Yes, eczema
3
Yes, psoriasis
4
Yes, localised loss of hair
5
Yes, generalised loss of hair
6
Yes, other skin complaint
7
Information insufficient
If Yes,
qc_17 >= 2 && qc_17 <== 6

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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ABDOMEN

Has the child ever had a hernia or a complaint involving the abdomen? Please ring all relevant codes.

1
No
2
Yes, recurrent abdominal pains
3
Yes, inguinal hernia
4
Yes, femoral hernia
5
Yes, other abdominal condition
6
Information insufficient
If Yes,
qc_18 >= 2 && qc_18 <= 5

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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UROGENITAL

Is the child incontinent of urine at present?

1
No
2
Yes, by day only
3
Yes, by night only
4
Yes, by day and night
5
Information insufficient
If Yes,
qc_19 == 2 || qc_19 == 3 || qc_19 == 4

Approximate number of nights incontinent per month

How many

Approximate number of days incontinent per month

How many

Medical Action taken

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Place of investigation/treatment

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Has the child ever had any abnormality affecting the kidneys, bladder, or genital tract? Please ring more than one code, if appropriate.

1
No
2
Yes, congenital abnormality of urogenital tract
3
Yes, nephritis
4
Yes, nephrosis
5
Yes, proven urinary infection(s)
6
Yes, other condition
7
Information insufficient
If Yes,
qc_20 >= 2 && qc_20 <= 6

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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ORTHOPAEDIC

Has the child ever had any bone, limb or joint condition, excluding fractures?

1
No
2
Yes, congenital abnormality of bone, limb or joint
3
Yes, acquired condition of bone, limb or joint
4
Yes, other condition
5
Information insufficient
If Yes,
qc_21 == 2 || qc_21 == 3 || qc_21 == 4

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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NEUROMUSCULAR, NEUROLOGICAL

Has the child ever had any condition affecting neurological function or disease of muscles? Include impairment of co-ordination, balance, sensation, etc. and any form of cerebral palsy.

1
No
2
Yes
3
Information insufficient
If Yes,
qc_22 == 2

Nature of condition

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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PSYCHIATRIC, PSYCHOLOGICAL

Has the child ever had any psychiatric or psychological opinion or treatment?

1
No
2
Yes
3
Information insufficient
If Yes,
qc_23 == 2

Nature of condition

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Age of diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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CONVULSIONS

Has the child ever had a convulsion?

1
No
2
Yes, before seventh birthday only
3
Yes, after seventh birthday only
4
Yes, both before and after seventh birthday
5
Information insufficient
If Yes,
qc_24 == 2 || qc_24 == 3 || qc_24 == 4

Type of convulsion (e.g. grand mal, petit mal)

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Age at first convulsion

Age

Frequency at present

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Nature of treatment

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Place of investigation/treatment

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Present condition

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MISCELLANEOUS

Which, if any, of the following operations has the child had?

1
Eye operation
2
Tonsillectomy
3
Inguinal hernia repair
4
Other hernia repair
5
Appendicectomy
6
Pylorotomy for pyloric stenosis
7
Circumcision
8
Other operation (not listed above)
9
NO OPERATION

Where appropriate, reason for operation:

Generic text

Age when performed

Age

Name and address of hospital(s)

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Has the child had any other illness or condition requiring specialist treatment or hospital admission not listed above?

1
No
2
Yes
3
Information insufficient
If Yes,
qc_26 == 2

Nature of condition, etc

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Age at diagnosis

Age

Action taken

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Place of investigation/treatment

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Present condition

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Please read carefully the 'INTRODUCTORY NOTES AND INSTRUCTIONS FOR THE NATIONAL CHILD DEVELOPMENT STUDY (N.C.D.S.) 11 YEAR EXAMINATION' before commencing examination
MEDICAL EXAMINATION

Has the child to your knowledge any congenital or acquired condition or handicap? Please enter conditions that might interfere permanently with entirely normal functioning, either at home or at school, or restrict choice of future employment.

1
Yes
2
No
3
Information insufficient
If Yes,
qc_27 == 1

please describe condition

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CHILD'S HEIGHT without shoes and socks. ... ft. ... in. ... part inch.

Feet
Inches in foot
Part inch
If unable to measure
qc_28 == NULL

state reason here

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CHILD'S WEIGHT (in vest and pants only) to the nearest pound. ... st. ... lb.

Stones
Pounds in stone
If unable to weigh
qc_29 == NULL

state reason here

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UPPER AND LOWER RESPIRATORY TRACTS

Please examine the nose, throat, palate, pharynx and chest, and ring as appropriate.

1
No abnormality
2
Marked nasal obstruction (recurrent or chronic)
3
Severe upper respiratory infection (recurrent or chronic)
4
Disease of mouth, tongue or palate
5
Other disease of upper respiratory tract
6
Bronchospasm
7
Chest deformity
8
Any other disease of lungs

Describe any abnormality ringed above

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EARS

Please examine both ears with an auroscope. LEFT EAR. Is the eardrum:

1
Normal
2
Inflamed
3
Scarred
4
Obscured by wax
5
Abnormal in any other way
6
Not examined

Describe any abnormality found

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Please examine both ears with an auroscope. RIGHT EAR. is the eardrum:

1
Normal
2
Inflamed
3
Scarred
4
Obscured by wax
5
Abnormal in any other way
6
Not examined

Describe any abnormality found

Generic text
CARDIOVASCULAR SYSTEM

Please examine the child's cardiovascular system. Are there any symptoms or physical signs of cardiac disease?

1
No
2
No, but murmur present which seems innocent
3
Yes, significant murmur
4
Yes, other abnormal physical sign
5
Not examined

Describe any abnormality found:

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ABDOMEN (including Uro-genital System)

Please examine the child's abdomen including hernial orifices and genitalia. Please ring as appropriate.

1
No abnormality
2
Abnormality of alimentary tract
3
Abnormality of kidneys or bladder
4
Inguinal hernia
5
Other hernia
6
Abnormality of external genitalia
7
Other Abnormality

Specify any abnormality found

Generic text
Leave blank for girls:
qc_2 == 2
Else

Have the testicles descended?

1
Yes
2
Both undescended or absent
3
Left undescended or absent
4
Right undescended or absent
5
Uncertain
6
Not examined
PUBERTY RATINGS
By reference to the Introductory Notes and Instructions for the Medical Examination, assess the stages of pubertal development and record below the appropriate rating from one to five (e.g. for Stage 1 development enter 1 ); if unable to assess enter 0 and state reason below:
-
Puberty rating
Boys: Genitalia rating
Boys: Pubic hair rating
Girls: Breast rating
Girls: Pubic Hair rating
Unable to assess,
qc_35 == '0'

state reason:

Generic text
SKIN

Please examine the skin, hair and nails and ring findings as appropriate

1
Nothing abnormal
2
Eczema
3
Psoriasis
4
Strawberry marks
5
Port wine stains
6
Common warts
7
Other skin conditions, hair or nail disorders

Specify any abnormality found

Generic text
LOCOMOTOR, SKELETAL AND CENTRAL NERVOUS SYSTEM
Inspect the muscles, bones and joints and then perform a brief neurological examination including:
Cranial nerves
Tendon reflexes
Muscle power, tone
Sensation

In the light of your examination and history is there:

1
Neurogical disorder
2
Muscular disorder
3
Congenital orthopaedic disorder
4
Recent fracture
5
Other acquired orthopaedic disorder
6
NONE OF ABOVE
7
Not examined
If 1, 2, 3, 4, or 5 is ringed:
qc_37 >= 1 && qc_37 <= 5

Please enter the diagnosis

Generic text

Are there any indications of abnormality/clumsiness?

1
Of balance
2
Of gait
3
In performing finger-nose test
4
In rapidly tapping the fingers of one hand on the dorsum of the other hand
SPEECH

Speech Test. (refer to 'Introductory Notes' before commencing test. Underline any mispronounced words and record the total. Test Sentences: The shop has run out of strawberry flavoured ice-cream. Stephen does not understand what the fuss is about. Gordon left his glasses on the chair. Perhaps Janet could fetch both of them. Carol screamed when she saw the spider on the couch. Total mispronounced words (e.g. for 8 enter 08)

How many
If unable to test, enter 99
qc_39 == '99'

and give reason.

Generic text
Speech Assessment

Does the child have a defect of articulation?

1
No
2
Yes, stammer or stutter
3
Yes, other speech abnormality
4
Don't know
If any 'other speech abnormality'
qc_40 == 3

please describe

Other
HEARING

Clinical Hearing Test. (See 'Introductory Notes' before commencing test.) Test Words Right Ear: Book Does Mouse Stick Three Pot Kind Field Hair Good Give Ball Train Had Big When Saw Can Last Poor Room Wash Floor One Said Enter total number of incorrect words, e.g. for 5 enter 05. Enter number

How many
If unable to test, enter 99
qc_41_a == '99'

and state reason

Generic text

Clinical Hearing Test. (See 'Introductory Notes' before commencing test.) Test Words Left Ear: Good Kind Said Field Ball Pot Room Big Hair Stock Had Mouse Last Train Book Poor Can When One Wash Give Does Three Saw Floor Enter total number of incorrect words. Enter number

How many
If unable to test, enter 99
qc_41_b == '99'

and state reason

Generic text

Does the child wear a hearing aid?

1
Yes
2
No
3
Don't know
If Yes,
qc_41_c == 1

repeat test using aid and enter total number of incorrect words. Left ear

How many

repeat test using aid and enter total number of incorrect words. Right ear

How many
42. Scrutiny of Audiogram Note
(1) Please scrutinise audiogram when available and compare the result with your clinical hearing test. If the two are not compatible, please arrange for a repeat audiogram if possible and send both audiograms to us.
(2) If audiogram has not yet been completed please arrange to look at it when available.
Hearing Assessment

In the light of your examination, would you consider that there is any hearing loss which would interfere with normal schooling and everyday functioning?

1
Normal hearing, no interference
2
Hearing loss but no interference
3
Hearing loss and some interference
4
Can't say
5
Not tested
EYES AND VISION

Squint Please examine the eyes for squint. Is there evidence of any of the following?

1
Nothing abnormal noted
2
Squint with left eye
3
Squint with right eye
4
Squint with both eyes

Describe type of squint, if known.

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Distant Vision Without glasses. If unable to test please ring '0'. Please ring Left eye

1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test

Distant Vision Without glasses. If unable to test please ring '0'. Please ring Right eye

1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test
If unable to test
qc_45_a_i == 0 || qc_45_a_ii == 0

please give reason

Generic text

Distant Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Left eye

X
X
Y
Y
1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test

Distant Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Right eye

X
X
Y
Y
1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test

Does the Snellen far vision chart used for your examination measure 6 vision?

1
Yes
2
No

Near vision Without glasses. If unable to test please ring '0'. Left eye

1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test

Near vision Without glasses. If unable to test please ring '0'. Right eye

1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test
If unable to test
qc_46_a_i == 0 || qc_46_a_ii == 0

please give reason

Generic text

Near Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Left eye

X
X
Y
Y
1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test

Near Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Right eye

X
X
Y
Y
1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test

Colour Vision Test colour vision with Ishihara plates if available

1
Normal colour vision
2
Impairment of red/green vision
3
Other colour loss
4
Could not test
If colour loss revealed on test,
qc_47 == 2 || qc_47 == 3

describe type and severity of colour blindness.

Generic text
For children with some abnormality of vision.

Please indicate type of condition

1
Hypermetropia (spectacle lens magnifies object)
2
Myopia (spectacle lens diminishes object)
3
Astigmatism (when spectacle lens is rotated vertical objects tilt)
4
Other visual abnormality

Please describe any 'other visual abnormality'

Other
Visual Assessment

In the light of your examination and the history would you consider that there is any interference with normal schooling and everyday functioning?

1
Normal vision, no interference
2
Visual defect, but with no interference
3
Visual defect and some interference
4
Don't know
LATERALITY

Please assess laterality Ask child to throw ball to you. Did he/she use:

1
Right hand
2
Left hand
3
Not examined

Please assess laterality Ask child to kick ball to you. Did he/she use:

1
Right foot
2
Left foot
3
Not examined

Please assess laterality Ask child to look through a rolled-up paper tube. Did he/she use:

1
Right eye
2
Left eye
3
Not examined
MOTOR CO-ORDINATION TESTS
See 'Introductory Notes and Instructions for Medical Examination' for description of tests and exact method of scoring. Ring appropriate numbers below for scoring.

WALKING BACKWARDS ALONG A LINE

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
If test not performed or scored
qc_51 == 4 || qc_51 == 5 || qc_51 == 6

state reason

Generic text

STANDING ON RIGHT FOOT FOR 15 SECONDS

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
If test not performed or scored
qc_52_a == 4 || qc_52_a == 5 || qc_52_a == 6

state reason.

Generic text

STANDING ON LEFT FOOT FOR 15 SECONDS

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
If test not performed or scored
qc_52_b == 4 || qc_52_b == 5 || qc_52_b == 6

state reason.

Generic text

STANDING HEEL TO TOE FOR 15 SECONDS

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
If test not performed or scored
qc_53 == 4 || qc_53 == 5 || qc_53 == 6

state reason.

Generic text

TENNIS BALL Record number of successful catches and bounces out of ten with each hand, e.g. if 5 successful catches enter 05. Right hand-number of catches

Catches

TENNIS BALL Record number of successful catches and bounces out of ten with each hand, e.g. if 5 successful catches enter 05. Left hand-number of catches

Catches
If test not performed or scored,
qc_54_i == NULL && qc_54_ii == NULL

state reason

Generic text

SQUARES MARKED (on page 12) Enter number of squares marked with each hand, e.g.for 95 squares, enter 095 Right hand-squares marked

Squares

SQUARES MARKED (on page 12) Enter number of squares marked with each hand, e.g. for 95 squares, enter 095 Left hand-squares marked

Squares
If test not performed or scored,
qc_55_i == NULL && qc_55_ii == NULL

state reason.

Generic text

PICKING UP MATCHES Enter time in seconds to pick up 20 matches. If 99 seconds or over, enter 99. Right hand-number of seconds

Seconds

PICKING UP MATCHES Enter time in seconds to pick up 20 matches. If 99 seconds or over, enter 99. Left hand-number of seconds

Seconds
If test not performed or scored,
qc_56_i == NULL && qc_56_ii == NULL

state reason.

Generic text

From the child's features please place him/her in one of the following broad categories.

1
European or Caucasian
2
African or Negroid
3
Indian or Pakistani
4
Other Asian
5
Other (please describe)
Other
END OF MEDICAL EXAMINATION
Please express the thanks of the Study to the child and parent(s) for their co-operation.
Please now recheck the form and then return it to your Local Authority's head office (unless other instructions have been given locally).
To Local Authority Officer supervising the survey
Please scrutinise this form and if possible complete or add any further information which is available from central records.
End

ncds_69_mq

STRICTLY CONFIDENTIAL
Local Authority code number
Local Authority Code number
Child's Code number
Child's Code number
MEDICAL EXAMINATION FORM*
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
SPONSORED AND ADMINISTERED BY: National Bureau for Co-operation in Child Care
CO-SPONSORED BY:
Institute of Child Health, University of London
National Birthday Trust Fund
National Foundation for Educational Research in England and Wales
IN COLLABORATION WITH:
ENGLAND AND WALES
Association of Chief Education Officers
Society of Medical Officers of Health
SCOTLAND
Association of Directors of Education
Association of School Medical and Dental Officers
CHAIRMAN OF CONSULTATIVE COMMITTEE:
Mary D. Sheridan, O.B.E., M.A., M.D., D.C.H.
CHAIRMAN OF STEERING COMMITTEE: W.D. Wall, B.A., PH.D.
EXECUTIVE CO-DIRECTORS:
Professor N. R. Butler, M.D., F.R.C.P., D.C.H.
Mrs. M. L. Kellmer Pringle, B.A., PH.D., DIP. ED. PSYCH.
CO-DIRECTOR AND PRINCIPAL INVESTIGATOR:
R. Davie, B.A., DIP.ED.PSYCH.
CO-DIRECTORS: M. J. R. Healy, B.A.
J. M. Tanner, M.D., D.SC , M.R.C.P.
W.D. Wall, B.A., PH.D.
SENIOR RESEARCH OFFICER:
P. J. Wedge, M.A., DIP.PUB.SOC.ADMIN., DIP.APP.SOC.STUD.
CHILD'S NAME (Surname)
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CHILD'S NAME (Christian Names)
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CHILD'S SEX (Please ring appropriate number)
1
Boy
2
Girl
TODAY'S DATE
Generic date
CHILD'S PRESENT HOME ADDRESS
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NAME OF MEDICAL EXAMINER (Block Capitals)
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IS CHILD ACCOMPANIED BY:
1
Mother
2
Other adult (specify)
3
No adult
CHILD'S DATE OF BIRTH
Date of birth
*Please read carefully the 'INTRODUCTORY NOTES AND INSTRUCTIONS FOR THE NATIONAL CHILD DEVELOPMENT STUDY (N.C.D.S.) 11 YEAR EXAMINATION' before completing the form.

Have you the following records at your disposal now or when completing this form?

-

1 - Yes

2 - No

Completed parental interview form
Infant Welfare Record
School Medical Record (Form 10M in England and Wales, School Medical Card in Scotland)
Has a decision been reached by the Local Authority that the child is in need of 'special educational treatment' or exclusion from school?
1
No, and not likely to be required
2
No, but a decision pending
3
Yes, but waiting for a place
4
Yes, and receiving special educational treatment
5
Don't know
into which of the following categories does the child fall?
1
Blind
2
Partially sighted
3
Deaf
4
Partially hearing
5
Educationally subnormal
6
Severely subnormal
7
Epileptic
8
Maladjusted
9
Physically handicapped
X
Speech defect
Y
Delicate
Do you have access to special records relating to the handicapping condition, e.g. form 2HP, 4HP (MH3 in Scotland) in completing this form?
1
Yes
2
No
please list form(s) available
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MEDICAL HISTORY

Please amplify any relevant conditions in the following list, giving further details of diagnosis, age at diagnosis, action taken (e.g. operation, type of medical treatment, and place of treatment). When G.P. has treated, write simply 'G.P.' but for hospitals and non-G.P. clinics please give full name and address. Space for this is afforded on the right of the page.

VISION

Has child ever been found to have an abnormal eye condition (including squint)?
1
Never
2
Yes, transient complaint now recovered
3
Yes, permanent condition
4
Information insufficient
state which eye
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Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Does child usually wear glasses?
1
No
2
Yes, for reading only
3
Yes, all the time
4
Information insufficient
5
Other (please specify)
Other

HEARING

Has the child ever had impaired hearing?
1
No
2
Yes, congenital condition
3
Yes, acquired condition (permanent)
4
Yes, acquired condition (transient)
5
Yes, cause uncertain
6
Information insufficient
which ear
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Nature of severity of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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UPPER RESPIRATORY SYSTEM

Has child ever had any abnormality of the ear/nose/throat/palate (other than transient)? Do not include impaired hearing.
1
No
2
Yes
3
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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LOWER RESPIRATORY SYSTEM

Has the child ever had wheezy bronchitis or asthma (other than mild attacks in infancy)?
1
No
2
Yes, before seventh birthday
3
Yes, after seventh birthday
4
Yes, both before and after seventh birthday
5
Information insufficient
Type of attacks
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Age at first attack (if known)
Age
Frequency at present
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Severity at present
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Degree of disability at present
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How treated, e.g. inhalers, steroids
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Place of investigation/treatment
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Has the child ever had a non-asthmatic chest complaint?
1
No
2
Yes
3
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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HEART

Has the child ever had any abnormal heart condition?
1
No
2
Yes, congenital disorder
3
Yes, acquired disorder
4
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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SKIN

Has the child ever had a recurrent skin complaint? Please ring all relevant codes.
1
No
2
Yes, eczema
3
Yes, psoriasis
4
Yes, localised loss of hair
5
Yes, generalised loss of hair
6
Yes, other skin complaint
7
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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ABDOMEN

Has the child ever had a hernia or a complaint involving the abdomen? Please ring all relevant codes.
1
No
2
Yes, recurrent abdominal pains
3
Yes, inguinal hernia
4
Yes, femoral hernia
5
Yes, other abdominal condition
6
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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UROGENITAL

Is the child incontinent of urine at present?
1
No
2
Yes, by day only
3
Yes, by night only
4
Yes, by day and night
5
Information insufficient
Approximate number of nights incontinent per month
How many
Approximate number of days incontinent per month
How many
Medical Action taken
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Place of investigation/treatment
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Has the child ever had any abnormality affecting the kidneys, bladder, or genital tract? Please ring more than one code, if appropriate.
1
No
2
Yes, congenital abnormality of urogenital tract
3
Yes, nephritis
4
Yes, nephrosis
5
Yes, proven urinary infection(s)
6
Yes, other condition
7
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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ORTHOPAEDIC

Has the child ever had any bone, limb or joint condition, excluding fractures?
1
No
2
Yes, congenital abnormality of bone, limb or joint
3
Yes, acquired condition of bone, limb or joint
4
Yes, other condition
5
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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NEUROMUSCULAR, NEUROLOGICAL

Has the child ever had any condition affecting neurological function or disease of muscles? Include impairment of co-ordination, balance, sensation, etc. and any form of cerebral palsy.
1
No
2
Yes
3
Information insufficient
Nature of condition
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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PSYCHIATRIC, PSYCHOLOGICAL

Has the child ever had any psychiatric or psychological opinion or treatment?
1
No
2
Yes
3
Information insufficient
Nature of condition
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Age of diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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CONVULSIONS

Has the child ever had a convulsion?
1
No
2
Yes, before seventh birthday only
3
Yes, after seventh birthday only
4
Yes, both before and after seventh birthday
5
Information insufficient
Type of convulsion (e.g. grand mal, petit mal)
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Age at first convulsion
Age
Frequency at present
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Nature of treatment
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Place of investigation/treatment
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Present condition
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MISCELLANEOUS

Which, if any, of the following operations has the child had?
1
Eye operation
2
Tonsillectomy
3
Inguinal hernia repair
4
Other hernia repair
5
Appendicectomy
6
Pylorotomy for pyloric stenosis
7
Circumcision
8
Other operation (not listed above)
9
NO OPERATION
Where appropriate, reason for operation:
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Age when performed
Age
Name and address of hospital(s)
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Has the child had any other illness or condition requiring specialist treatment or hospital admission not listed above?
1
No
2
Yes
3
Information insufficient
Nature of condition, etc
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Age at diagnosis
Age
Action taken
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Place of investigation/treatment
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Present condition
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Please read carefully the 'INTRODUCTORY NOTES AND INSTRUCTIONS FOR THE NATIONAL CHILD DEVELOPMENT STUDY (N.C.D.S.) 11 YEAR EXAMINATION' before commencing examination

MEDICAL EXAMINATION

Has the child to your knowledge any congenital or acquired condition or handicap? Please enter conditions that might interfere permanently with entirely normal functioning, either at home or at school, or restrict choice of future employment.
1
Yes
2
No
3
Information insufficient
please describe condition
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CHILD'S HEIGHT without shoes and socks. ... ft. ... in. ... part inch.
Feet
Inches in foot
Part inch
state reason here
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CHILD'S WEIGHT (in vest and pants only) to the nearest pound. ... st. ... lb.
Stones
Pounds in stone
state reason here
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UPPER AND LOWER RESPIRATORY TRACTS

Please examine the nose, throat, palate, pharynx and chest, and ring as appropriate.
1
No abnormality
2
Marked nasal obstruction (recurrent or chronic)
3
Severe upper respiratory infection (recurrent or chronic)
4
Disease of mouth, tongue or palate
5
Other disease of upper respiratory tract
6
Bronchospasm
7
Chest deformity
8
Any other disease of lungs
Describe any abnormality ringed above
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EARS

Please examine both ears with an auroscope. LEFT EAR. Is the eardrum:
1
Normal
2
Inflamed
3
Scarred
4
Obscured by wax
5
Abnormal in any other way
6
Not examined
Describe any abnormality found
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Please examine both ears with an auroscope. RIGHT EAR. is the eardrum:
1
Normal
2
Inflamed
3
Scarred
4
Obscured by wax
5
Abnormal in any other way
6
Not examined
Describe any abnormality found
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CARDIOVASCULAR SYSTEM

Please examine the child's cardiovascular system. Are there any symptoms or physical signs of cardiac disease?
1
No
2
No, but murmur present which seems innocent
3
Yes, significant murmur
4
Yes, other abnormal physical sign
5
Not examined
Describe any abnormality found:
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ABDOMEN (including Uro-genital System)

Please examine the child's abdomen including hernial orifices and genitalia. Please ring as appropriate.
1
No abnormality
2
Abnormality of alimentary tract
3
Abnormality of kidneys or bladder
4
Inguinal hernia
5
Other hernia
6
Abnormality of external genitalia
7
Other Abnormality
Specify any abnormality found
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Have the testicles descended?
1
Yes
2
Both undescended or absent
3
Left undescended or absent
4
Right undescended or absent
5
Uncertain
6
Not examined

PUBERTY RATINGS

By reference to the Introductory Notes and Instructions for the Medical Examination, assess the stages of pubertal development and record below the appropriate rating from one to five (e.g. for Stage 1 development enter 1 ); if unable to assess enter 0 and state reason below:

-
Puberty rating
Boys: Genitalia rating
Boys: Pubic hair rating
Girls: Breast rating
Girls: Pubic Hair rating
state reason:
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SKIN

Please examine the skin, hair and nails and ring findings as appropriate
1
Nothing abnormal
2
Eczema
3
Psoriasis
4
Strawberry marks
5
Port wine stains
6
Common warts
7
Other skin conditions, hair or nail disorders
Specify any abnormality found
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LOCOMOTOR, SKELETAL AND CENTRAL NERVOUS SYSTEM

Inspect the muscles, bones and joints and then perform a brief neurological examination including:
Cranial nerves
Tendon reflexes
Muscle power, tone
Sensation
In the light of your examination and history is there:
1
Neurogical disorder
2
Muscular disorder
3
Congenital orthopaedic disorder
4
Recent fracture
5
Other acquired orthopaedic disorder
6
NONE OF ABOVE
7
Not examined
Please enter the diagnosis
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Are there any indications of abnormality/clumsiness?
1
Of balance
2
Of gait
3
In performing finger-nose test
4
In rapidly tapping the fingers of one hand on the dorsum of the other hand

SPEECH

Speech Test. (refer to 'Introductory Notes' before commencing test. Underline any mispronounced words and record the total. Test Sentences: The shop has run out of strawberry flavoured ice-cream. Stephen does not understand what the fuss is about. Gordon left his glasses on the chair. Perhaps Janet could fetch both of them. Carol screamed when she saw the spider on the couch. Total mispronounced words (e.g. for 8 enter 08)
How many
and give reason.
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Speech Assessment
Does the child have a defect of articulation?
1
No
2
Yes, stammer or stutter
3
Yes, other speech abnormality
4
Don't know
please describe
Other

HEARING

Clinical Hearing Test. (See 'Introductory Notes' before commencing test.) Test Words Right Ear: Book Does Mouse Stick Three Pot Kind Field Hair Good Give Ball Train Had Big When Saw Can Last Poor Room Wash Floor One Said Enter total number of incorrect words, e.g. for 5 enter 05. Enter number
How many
and state reason
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Clinical Hearing Test. (See 'Introductory Notes' before commencing test.) Test Words Left Ear: Good Kind Said Field Ball Pot Room Big Hair Stock Had Mouse Last Train Book Poor Can When One Wash Give Does Three Saw Floor Enter total number of incorrect words. Enter number
How many
and state reason
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Does the child wear a hearing aid?
1
Yes
2
No
3
Don't know
repeat test using aid and enter total number of incorrect words. Left ear
How many
repeat test using aid and enter total number of incorrect words. Right ear
How many
42. Scrutiny of Audiogram Note
(1) Please scrutinise audiogram when available and compare the result with your clinical hearing test. If the two are not compatible, please arrange for a repeat audiogram if possible and send both audiograms to us.
(2) If audiogram has not yet been completed please arrange to look at it when available.
Hearing Assessment
In the light of your examination, would you consider that there is any hearing loss which would interfere with normal schooling and everyday functioning?
1
Normal hearing, no interference
2
Hearing loss but no interference
3
Hearing loss and some interference
4
Can't say
5
Not tested

EYES AND VISION

Squint Please examine the eyes for squint. Is there evidence of any of the following?
1
Nothing abnormal noted
2
Squint with left eye
3
Squint with right eye
4
Squint with both eyes
Describe type of squint, if known.
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Distant Vision Without glasses. If unable to test please ring '0'. Please ring Left eye
1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test
Distant Vision Without glasses. If unable to test please ring '0'. Please ring Right eye
1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test
please give reason
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Distant Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Left eye
X
X
Y
Y
1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test
Distant Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Right eye
X
X
Y
Y
1
6/3
2
6/6
3
6/9
4
6/12
5
6/18
6
6/24
7
6/36
8
6/60
9
Worse than 6/60 or blind
0
Unable to test
Does the Snellen far vision chart used for your examination measure 6 vision?
1
Yes
2
No
Near vision Without glasses. If unable to test please ring '0'. Left eye
1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test
Near vision Without glasses. If unable to test please ring '0'. Right eye
1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test
please give reason
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Near Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Left eye
X
X
Y
Y
1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test
Near Vision Retest with glasses. If child does not wear glasses ring 'X'. If glasses prescribed but not available ring 'Y'. Right eye
X
X
Y
Y
1
6
2
9
3
12
4
18
5
24
6
36
7
60
9
Worse than 60 or blind
0
Unable to test
Colour Vision Test colour vision with Ishihara plates if available
1
Normal colour vision
2
Impairment of red/green vision
3
Other colour loss
4
Could not test
describe type and severity of colour blindness.
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Please indicate type of condition
1
Hypermetropia (spectacle lens magnifies object)
2
Myopia (spectacle lens diminishes object)
3
Astigmatism (when spectacle lens is rotated vertical objects tilt)
4
Other visual abnormality
Please describe any 'other visual abnormality'
Other
Visual Assessment
In the light of your examination and the history would you consider that there is any interference with normal schooling and everyday functioning?
1
Normal vision, no interference
2
Visual defect, but with no interference
3
Visual defect and some interference
4
Don't know

LATERALITY

Please assess laterality Ask child to throw ball to you. Did he/she use:
1
Right hand
2
Left hand
3
Not examined
Please assess laterality Ask child to kick ball to you. Did he/she use:
1
Right foot
2
Left foot
3
Not examined
Please assess laterality Ask child to look through a rolled-up paper tube. Did he/she use:
1
Right eye
2
Left eye
3
Not examined

MOTOR CO-ORDINATION TESTS

See 'Introductory Notes and Instructions for Medical Examination' for description of tests and exact method of scoring. Ring appropriate numbers below for scoring.
WALKING BACKWARDS ALONG A LINE
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
state reason
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STANDING ON RIGHT FOOT FOR 15 SECONDS
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
state reason.
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STANDING ON LEFT FOOT FOR 15 SECONDS
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
state reason.
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STANDING HEEL TO TOE FOR 15 SECONDS
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Could not score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
state reason.
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TENNIS BALL Record number of successful catches and bounces out of ten with each hand, e.g. if 5 successful catches enter 05. Right hand-number of catches
Catches
TENNIS BALL Record number of successful catches and bounces out of ten with each hand, e.g. if 5 successful catches enter 05. Left hand-number of catches
Catches
state reason
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SQUARES MARKED (on page 12) Enter number of squares marked with each hand, e.g.for 95 squares, enter 095 Right hand-squares marked
Squares
SQUARES MARKED (on page 12) Enter number of squares marked with each hand, e.g. for 95 squares, enter 095 Left hand-squares marked
Squares
state reason.
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PICKING UP MATCHES Enter time in seconds to pick up 20 matches. If 99 seconds or over, enter 99. Right hand-number of seconds
Seconds
PICKING UP MATCHES Enter time in seconds to pick up 20 matches. If 99 seconds or over, enter 99. Left hand-number of seconds
Seconds
state reason.
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From the child's features please place him/her in one of the following broad categories.
1
European or Caucasian
2
African or Negroid
3
Indian or Pakistani
4
Other Asian
5
Other (please describe)
Other
END OF MEDICAL EXAMINATION
Please express the thanks of the Study to the child and parent(s) for their co-operation.
Please now recheck the form and then return it to your Local Authority's head office (unless other instructions have been given locally).
To Local Authority Officer supervising the survey
Please scrutinise this form and if possible complete or add any further information which is available from central records.
Name

NCDS Age 11 Medical Examination