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ncds_65_mq
STRICTLY CONFIDENTIAL
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
SPONSORS:
Institute of Child Health, University of London
National Birthday Trust Fund
National Bureau for Co-operation in Child Care
National Foundation for Education 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: Sir Lionel Russell, C.B.E., M.A.
CO-CHAIRMEN OF STEERING COMMITTEE:
H. L. Elvin, M.A.
W. D. Wall, B.A., Ph.D.
CO-DIRECTORS:
Neville R. Butler, M.D., M.R.C.P, D.C.H.
Mrs. M. L. Kellmor Pringle, B.A., Ph.D., Dip. Ed. Psych.
SENIOR RESEARCH OFFICER: R. Davie, B.A.
SENIOR MEDICAL OFFICER: M. J. Ball, B.Sc., M.B., B.S., D.P.H.
MEDICAL QUESTIONNAIRE

Local Authority Code Number

Local Authority Code Number

Child's Code Number

Child's Code Number

CHILD'S NAME (Surname)

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CHILD'S NAME (Christian Names)

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SEX

1
Boy
2
Girl

DATE OF BIRTH

Date of birth

ADDRESS OF MEDICAL EXAMINATION

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DATE OF MEDICAL EXAMINATION

Generic date

NAME OF MEDICAL EXAMINER

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DESIGNATION

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INTRODUCTORY NOTES
The Purpose of the Study
Shortly after their birth, all these children were the subject of a comprehensive investigation into the circumstances relating to the mother and child, the pregnancy and the birth. The results of this study published in the Perinatal Mortality Survey have already had a world-wide influence, and it is hoped that the many doctors and midwives who were involved feel that their efforts have been fully justified.
The National Child Development Study is a logical extension of the original investigation to the growing child. Not only is there the need to assess the present physical, educational and emotional status of the child population, but for the first time there is an opportunity to relate these assessments to the existing obstetric and social data of this large national sample.
Considerable interest is already focussed on the major handicaps of childhood, but much remains to be discovered about the true incidence of these conditions and their aetiology. Even less is known of the incidence and cause of minor disabilities, emotional maladjustments and educational handicaps. This study will throw some light on their occurence amongst children considered "at risk" of developing handicapping conditions.
This study will also reveal the numbers of children who have been exposed to such predisposing factors, but who are nevertheless developing normally.
The Scope of the Investigation
The Study is based on information gathered from three sources.
(i) The school is assessing the child's educational progress and social adjustment and is applying some attainment tests. This aspect of the investigation is being undertaken by the Local Education Department.
(ii) The mother of the child is interviewed by a Health Visitor (in most instances) who completes a Parental Questionnaire concerning the child's early life and environment. Details of illnesses, operations and a full medical history are included in this questionnaire, and on completion it will be passed on to the doctor for reference during his examination of the child.
(iii) The Medical Questionnaire comprises a medical history and examination, tests of vision, speech and hearing, physical measurements and a urine test. It is also hoped that an Audiogram will be obtained, at a time convenient to the School Health Department.
NOTES ON THE MEDICAL QUESTIONNAIRE
The form of this questionnaire has been determined by the need to utilise modern methods of handling a large volume of data. Except where stated otherwise, each question is answered by putting a ring round the appropriate number in each box.
The following order of completion is suggested as the most practical:
With the child dressed:
(1) Front page.
(2) Medical History. N.B.: Since these questions, on pages, 4, 6, 8, are identical with pages 16, 17, 18 of the Parental Questionnaire. It is not necessary for the doctor to take a second medical history if the latter is to hand and has been answered to his satisfaction.
(3) Vision, Speech and Hearing tests.
(4) Uristix urine test.
With the child undressed:
(5) Height, Weight and Head circumference.
(6) Medical examination.
(7) Completion of questionnaire.

Is the child accompanied at this medical examination by:

1
Mother
2
Father
3
Other relative (Specify)
4
Other person (Specify)
0
Child unaccompanied
Other

Is the Parental Questionnaire in hand for reference?

1
Yes
2
No

CHILD'S HEIGHT, without shoes, to nearest inch (e.g., for 48 1/2 inches, enter 49).

Inches I
If unable to measure, enter 00
qc_3 == '00'

and state reason

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A few areas have been issued with pocket stadiometers.
If issued with a stadiometer,

CHILD'S HEIGHT, without shoes, to nearest centimeter (e.g. for 126 cms. enter 126).

Centimetres

CHILD'S WEIGHT, in underclothes, to nearest pound (e.g. for 53 1/2 lb. enter 54).

Pounds
If unable to weigh, enter 00
qc_4 == '00'

and state reason

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HEAD CIRCUMFERENCE, to nearest 0.5 inch (e.g. for 20 1/2 inches enter 20.5).

Inches F
If unable to measure, enter 00.0
qc_5 == '00.0'

and state reason

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MEDICAL HISTORY
GENERAL

Has the child, to the mother's knowledge, any physical handicap or disabling condition? Specify

2
No
1
Yes
0
Don't know
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Does the mother consider the child to be particularly sensitive or highly strung? Specify

2
No
1
Yes
0
Don't know
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EAR, NOSE AND THROAT

Has the child had more than 3 throat and/or ear infections (with fever) in the past year?

2
No
1
Yes
0
Don't know

Has the child ever had: Hay fever or sneezing attacks

2
No
1
Yes
0
Don't know

Has the child ever had: Habitual snoring or mouth breathing

2
No
1
Yes
0
Don't know

Has the child ever had: Running ears (i.e. pus, not wax)

2
No
1
Yes
0
Don't know

Has the child ever had: Running ears (i.e. pus, not wax) No. of times in past 12 mths.

How many

Has the child ever had: Earache, without running ears

2
No
1
Yes
0
Don't know

Has the child ever had: Earache, without running ears No. of times in past 12 mths.

How many

Has the child ever had: Hearing difficulty (suspected or confirmed) Specify

Has the child ever had: Hearing difficulty (suspected or confirmed) Age

Age

Has the child ever had: Hearing difficulty (suspected or confirmed) Present now?

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Has the child ever had: Other ear trouble Specify

2
No
1
Yes
0
Don't know
Other
RESPIRATORY SYSTEM

Has the child ever had: Attacks of asthma

2
No
1
Yes
0
Don't know

Has the child ever had: Attacks of asthma No. of times in all

How many

Has the child ever had: Attacks of asthma No. of times in past 12 mths.

How many

Has the child ever had: Bronchitis with wheezing

2
No
1
Yes
0
Don't know

Has the child ever had: Bronchitis with wheezing No. of times in past 12 mths.

How many

Has the child ever had: Pneumonia

2
No
1
Yes
0
Don't know

Has the child ever had: Pneumonia At what age?

Age

Has the child ever had: Other respiratory disease Specify

2
No
1
Yes
0
Don't know
Other
C.V.S.

Has the child had: Rheumatic fever

2
No
1
Yes
0
Don't know

Has the child had: Rheumatic fever At what age?

Age

Has the child had: Chorea (St. Vitus' Dance)

2
No
1
Yes
0
Don't know

Has the child had: Chorea (St. Vitus' Dance) At what age?

Age

Has the child had: Congenital heart condition Specify

2
No
1
Yes
0
Don't know
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Has the child had: Parent, brother or sister with congenital heart condition Specify

2
No
1
Yes
0
Don't know
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MEDICAL EXAMINATION
GENERAL

Is there a major handicapping or disfiguring condition? (e.g. mongolism, blindness, deafness, cerebral palsy, hydrocephalus, mental retardation, etc.) Specify

2
No
1
Yes
0
Don't know
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E.N.T. AND MOUTH

Does examination reveal: Nasal obstruction Specify

2
No
1
Yes
0
Don't know
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Does examination reveal: Nasal or postnasal discharge Specify

2
No
1
Yes
0
Don't know
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Does examination reveal: Tonsils worthy of comment Comment

2
No
1
Yes
0
Don't know
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Does examination reveal: Mouth or palate abnormality Specify

2
No
1
Yes
0
Don't know
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Does examination reveal: Please add up total missing, filled and carious teeth (e.g. for 7 enter 07)

How many

Does examination reveal: Have any permanent incisors appeared?

2
No
1
Yes
0
Don't know

Does examination reveal: Enlarged cervical glands Specify

2
No
1
Yes
0
Don't know
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Does examination reveal: Signs of past or present otitis media (if drum obscured, ring "0" Specify

2
No
1
Yes
0
Don't know
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Does examination reveal: Deformity of external ear Specify

2
No
1
Yes
0
Don't know
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Does examination reveal: Deformity of external ear R. or L.

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Does examination reveal: Other ear condition Specify

2
No
1
Yes
0
Don't know
Other
R.S.

Abnormal signs in lungs Specify

2
No
1
Yes
0
Don't know
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Abnormal chest shape Specify

2
No
1
Yes
0
Don't know
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Other respiratory condition Specify

2
No
1
Yes
0
Don't know
Other
C.V.S.

Pathological heart condition Specify

2
No
1
Yes
0
Don't know
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Other heart murmur Specify

2
No
1
Yes
0
Don't know
Other

Any other sign of heart disease (e.g. clubbing, cyanosis, etc.) Specify

2
No
1
Yes
0
Don't know
Other
MEDICAL HISTORY
ALIMENTARY AND UROGENITAL SYSTEMS

Has the child ever been/or had: Periodic vomiting or bilious attacks

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Periodic vomiting or bilious attacks No. of times in past 12 mths.

How many

Has the child ever been/or had: Periodic abdominal pain

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Periodic abdominal pain No. of times in past 12 mths.

How many

Has the child ever been/or had: Recurrent mouth ulcers

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Hernia of any sort

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Hernia of any sort Site

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Has the child ever been/or had: Other serious digestive, bowel or alimentary disorder Specify

2
No
1
Yes
0
Don't know
Other

Has the child ever been/or had: Infection in the urine (requiring medical treatment)

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Infection in the urine (requiring medical treatment) No. of times in all

How many

Has the child ever been/or had: Infection in the urine (requiring medical treatment) No. of times in past 12 mths.

How many

Has the child ever been/or had: Wet by day after 3 years of age (Ignore occasional mishaps)

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Wet by day after 3 years of age (Ignore occasional mishaps) How often in past 12 mths.

How many

Has the child ever been/or had: Wet by night after 5 years of age (Ignore occasional mishaps)

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Wet by night after 5 years of age (Ignore occasional mishaps) How often in past 12 mths.

How many

Has the child ever been/or had: Soiled by day after 4 years of age (Ignore occasional mishaps)

2
No
1
Yes
0
Don't know

Has the child ever been/or had: Soiled by day after 4 years of age (Ignore occasional mishaps) How often in past 12 mths.

How many

Has the child ever been/or had: Nephritis or other kidney or U-G disorder Specify

2
No
1
Yes
0
Don't know
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Has the child ever been/or had: Nephritis or other kidney or U-G disorder Age

Age

Has the child ever been/or had: Parent, brother or sister with disorder of alimentary or U-G tract Specify

2
No
1
Yes
0
Don't know
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METABOLISM AND BLOOD

Is there a history of: Sugar diabetes

2
No
1
Yes
0
Don't know

Is there a history of: Sugar diabetes Age of onset

Age

Is there a history of: Any diabetes in parents, brothers or sisters Specify

2
No
1
Yes
0
Don't know
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Is there a history of: Any thyroid, pituitary or adrenal gland disorder Specify

2
No
1
Yes
0
Don't know
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Is there a history of: Any blood disorder Specify

2
No
1
Yes
0
Don't know
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SKIN

Is there a history of: Eczema in the first year

2
No
1
Yes
0
Don't know

Is there a history of: Eczema in the first year Month of onset

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Is there a history of: Eczema in the first year Sites

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Is there a history of: Eczema after the first year

2
No
1
Yes
0
Don't know

Is there a history of: Eczema after the first year Any present now?

Generic text

Is there a history of: Eczema after the first year Sites

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Is there a history of: "Strawberry marks" (raised vascular naevi)

2
No
1
Yes
0
Don't know

Is there a history of: "Strawberry marks" (raised vascular naevi) Age

Age

Is there a history of: "Strawberry marks" (raised vascular naevi) Site

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Is there a history of: "Port wine stains" (flat vascular naevi)

2
No
1
Yes
0
Don't know

Is there a history of: "Port wine stains" (flat vascular naevi) Age

Age

Is there a history of: "Port wine stains" (flat vascular naevi) Site

Generic text

Is there a history of: Other skin condition, including hair or nail disorder Specify

2
No
1
Yes
0
Don't know
Other
MEDICAL EXAMINATION
ALIMENTARY AND UROGENITAL SYSTEMS

On examination, has the child: Inguinal hernia

2
No
1
Yes
0
Don't know

On examination, has the child: Inguinal hernia R. or L.

Generic text

On examination, has the child: Other hernia Specify

2
No
1
Yes
0
Don't know
Other

On examination, has the child: Urinary incontinence

2
No
1
Yes
0
Don't know

On examination, has the child: Partially or undescended testes

2
No
1
Yes
0
Don't know

On examination, has the child: Partially or undescended testes Specify R. or L. (count retractile testes as normal)

Generic text

On examination, has the child: Been circumcised

2
No
1
Yes
0
Don't know

On examination, has the child: Other U-G abnormality Specify

2
No
1
Yes
0
Don't know
Other

On examination, has the child: Other abdominal abnormality Specify

2
No
1
Yes
0
Don't know
Other
SKIN, BLOOD, Etc.

On examination is there: Bruising or petechiae Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Any lymph gland enlargement Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Eczema

2
No
1
Yes
0
Don't know

On examination is there: Eczema Sites

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On examination is there: Eczema Severity

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On examination is there: Birthmarks

2
No
1
Yes
0
Don't know

On examination is there: Birthmarks Sites

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On examination is there: Other skin condition, including hair or nail disorder Specify

2
No
1
Yes
0
Don't know
Other
URISTIX URINE TEST
Instructions:
Dip test end of strip in urine and remove imediately.

Compare colour of tip with protein colour chart at once

1
Negative (yellow)
2
Trace
3
Positive (green)
0
Don't know or not tested

Observe colour of band (glucose) after 10 seconds

1
Negative (red)
2
Positive (purple)
0
Don't know or not tested
MEDICAL HISTORY
C.N.S. and SKELETAL SYSTEM

Has the child had: A fit or convulsion in the first year of life

2
No
1
Yes
0
Don't know

Has the child had: A fit or convulsion in the first year of life How many in first year

How many

Has the child had: A fit or convulsion in the first year of life Age at first fit

Age

Has the child had: A fit or convulsion after the first year

2
No
1
Yes
0
Don't know

Has the child had: A fit or convulsion after the first year No. of times in past 12 mths.

How many

Has the child had: A fit or convulsion after the first year Total No. of fits

How many

Has the child had: Petit mal or "blank spells"

2
No
1
Yes
0
Don't know

Has the child had: Petit mal or "blank spells" Age at onset

Age

Has the child had: Petit mal or "blank spells" No. of times last year

How many

Any drug treatment for conditions (a), (b), (c)?

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Has the child had: Frequent headaches or migraine

2
No
1
Yes
0
Don't know

Has the child had: Frequent headaches or migraine No. of times in past 12 mths.

How many

Has the child had: Travel Sickness

2
No
1
Yes
0
Don't know

Has the child had: Travel Sickness Age

Age

Has the child had: Tics or habit spasms Specify

2
No
1
Yes
0
Don't know
Generic text

Has the child had: Tics or habit spasms Any in past 12 mths?

Generic text

Has the child had: Breath holding, head banging or "rocking" Specify

2
No
1
Yes
0
Don't know
Generic text

Has the child had: Breath holding, head banging or "rocking" At what age?

Age

Has the child had: Concussion or head injury (with unconsciousness) Specify

2
No
1
Yes
0
Don't know
Generic text

Has the child had: Concussion or head injury (with unconsciousness) Age

Age

Has the child had: Unusual size or shape of skull Specify

2
No
1
Yes
0
Don't know
Generic text

Has the child had: Any spinal trouble Specify

2
No
1
Yes
0
Don't know
Generic text

Has the child had: Congenital dislocation of hip

2
No
1
Yes
0
Don't know

Has the child had: Congenital dislocation of hip R. or L. or both?

Generic text

Has the child had: Talipes Specify type

2
No
1
Yes
0
Don't know
Generic text

Has the child had: Talipes R. or L. or both

Generic text

Has the child had: Any fractures

2
No
1
Yes
0
Don't know

Has the child had: Any fractures Site(s)

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Has the child had: Any fractures Age(s)

Generic text

Has the child had: Any other bone or joint disorder Specify

2
No
1
Yes
0
Don't know
Other

Has the child had: Has any parent, brother or sister had a fit or convulsion Specify

2
No
1
Yes
0
Don't know
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LATERALITY

Does the mother think the child is:

1
Right-handed
2
Left-handed
3
Mixed R. and L.
0
Don't know
VISION

Has the child ever had: Squint or suspected squint Specify

2
No
1
Yes
0
Don't know
Generic text

Has the child ever had: Squint or suspected squint Age

Age

Has the child ever had: Squint or suspected squint Present now?

Generic text

Has the child ever had: Any other eye trouble Specify

2
No
1
Yes
0
Don't know
Other

Has the child ever had: Have glasses been prescribed?

2
No
1
Yes
0
Don't know

Has the child ever had: Have glasses been prescribed? At what age?

Age

Has the child ever had: Have glasses been prescribed? Reason

Generic text
MEDICAL EXAMINATION
C.N.S. AND SKELETAL

On examination is there: Cerebral palsy

1
No
2
Spastic all four limbs.
3
Spastic hemiplegia.
4
Spastic monoplegia-upper limb.
5
Spastic monoplegia-lower limb.
6
Spastic both upper limbs.
7
Spastic both lower libs.
8
Athetosis and spasticity.
9
Athetosis alone.
X
Other (Specify)
Other

On examination is there: Tics or habit spasms Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Congenital upper limb defect (check symmetry of hands) Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Any malfunction of upper limb Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Skull deformity Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Spina bifida Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Other spinal disorder Specify

2
No
1
Yes
0
Don't know
Other

On examination is there: Congenital lower limb defect (Check symmetry effect) Specify

2
No
1
Yes
0
Don't know
Generic text

On examination is there: Talipes

2
No
1
Yes
0
Don't know

On examination is there: Talipes Type

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On examination is there: Talipes R. or L. or both

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On examination is there: Any malfunction of lower limb Specify

2
No
1
Yes
0
Don't know
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On examination is there: Other neurological or skeletal disorder Specify

2
No
1
Yes
0
Don't know
Other
LATERALITY TESTS
Please ask the child to carry out these tasks, and observe which hand/foot/eye is used.

Hand: Throw a crumpled paper ball. Draw a cross.

1
Only R. hand used
2
Only L. hand used
3
Both R. and L. hand used
0
Could not test

Foot: Kick crumpled paper ball. Hop on one leg.

1
Only R. foot used
2
Only L. foot used
3
Both R. and L. foot used
0
Could not test

Eye: Look through rolled paper tube. Look through hole in a card.

1
Only R. eye used
2
Only L. eye used
3
Both R. and L. eye used
0
Could not test
If unable to test, score 0
qc_24_a == 0 || qc_24_b == 0 || qc_24_c == 0

and state reason at foot of page.

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VISION TEST
Notes:
(1) Test at exactly 20 ft. with a standard Snellen chart of block capitals without seriphs.
(2) Hang the chart in a good light, level with the child's eyes, and free from glare.
(3) Please occlude the other eye efficiently without pressing on the eyeball.
(4) If the child does not know his letters and also gives an unsatisfactory response with the "E test", try again with the Snellen chart asking the child to "draw the letters in the air". If this fails, try a picture card.
(This order of procedure is recommended to avoid diagnosing a child with a spatio-visual difficulty as having a visual defect).

RESULT: Without glasses: R. Eye

Generic text
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason

RESULT: Without glasses: L. Eye

1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
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RESULT: With glasses: R. Eye

1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
0
0
Generic text

RESULT: With glasses: L. Eye

1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
0
0
Generic text

Is there evidence of: Squint

2
No
1
Yes
0
Don't know

Is there evidence of: Squint Specify R. or L.

Generic text

Is there evidence of: Squint Type

Generic text

Is there evidence of: Latent squint (cover test and "follow finger")

2
No
1
Yes
0
Don't know

Is there evidence of: Latent squint (cover test and "follow finger") Specify R. or L.

Generic text

Is there evidence of: Latent squint (cover test and "follow finger") Type

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Is there evidence of: Any other eye condition affecting vision Specify

2
No
1
Yes
0
Don't know
Other

Is there evidence of: Any other eye condition not affecting vision Sepcify

2
No
1
Yes
0
Don't know
Other

ASSESSMENT

1
Normal vision
2
Visual defect but no handicap to normal schooling and everyday activities
3
Can manage ordinary school books only with difficulty
4
Requires special school books and/or special visual aids
5
Blind, or vision insufficient to use special school books
0
Don't know, or unable to assess

ASSESSMENT Reason

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SPEECH TEST
Method:
(1) Position the child close to, and facing you.
(2) Please explain that you would like the test sentences repeated after you.
(3) Use a natural voice and observe the child's face during the replies.
(4) The sentences may be repeated if necessary.
(5) Please underline any mispronounced words (dropped aitches may be ignored) and record the total at the end.
(If unable to test, score 99

and state reason ...)

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Test sentences: Carol threaded a needle with wool. She mended her sister's frock. Roger grasped a bundle of sticks. Eating porridge gives him strength. My brother rode his bicycle to school. Phillip had scrambled eggs for breakfast. Total mispronounced words (e.g. for 8 enter 08).

How many

Is there any stammer?

1
No
2
slight
3
moderate
4
severe
0
Don't know

Assessment of intelligibility of speech:

1
Speech fully intelligible
2
Almost all words are intelligible
3
Many words are unintelligible
4
All or almost all words are unintelligible
0
Don't know or unable to test (Reason)
Generic text
HEARING TEST
Method:
(1) Conditions should be reasonably quiet.
(2) Position the child 10 feet away, with the ear under test towards you and the child's finger occluding the other ear.
(3) Ask the child to repeat each test word after you.
(4) The words should be spoken in a quiet conversational voice (not whispered), giving plenty of time for each reply.
(5) Please underline incorrect responses and record the totals.
(6) The assistance of a second person is desirable to hear the replies.
(If unable to test, score X

and state reason below.)

Generic text

Right Ear. Test words: shoes horse cart seat cup frock cat bike face chick fish ship Total incorrect responses

Response

Left Ear. Test words: spoon ball star feet bus sock hat knife cake pig dish ship Total incorrect responses

Response

Assessment of hearing:

1
Normal hearing
2
Some impairment of hearing (include those corrected by wearing a hearing aid)
3
Understanding of speech impaired (even with a hearing aid)
4
Speech not understood, even with a hearing aid and raised voice
0
Don't know, or unable to test

Assessment of hearing: Reason

Generic text

Has the child been formally "ascertained as in need of special educational treatment"? (If uncertain about this or the following questions, please check with P.S.M.O.) If "Yes", specify category:

1
No
0
Don't know
2
Blind
3
Partially sighted
4
Deaf
5
Partially hearing
6
Educationally subnormal
7
Epileptic
8
Maladjusted
9
Physically handicapped
X
Speech defect
Y
Delicate

Is the child receiving special educational treatment in a special school?

2
No
1
Yes
0
Don't know
if "Yes",
qc_28_b == 1

specify for which handicap

Generic text

Or in a special teaching unit?

2
No
1
Yes
0
Don't know
If "Yes",
qc_28_c == 1

specify for which handicap

Generic text

Is the child likely to be considered for a special school?

2
No
1
Yes
0
Don't know
If "Yes",
qc_28_d == 1

specify for which handicap

Generic text

Irrespective of local facilities, which of the following would you consider most suited to the child's educational needs?

1
Ordinary school
2
Ordinary school with remedial class or extra teaching help (for educational or mental backwardness, etc.)
3
Ordinary school with specially equipped teaching unit (for part sighted, part hearing, etc.)
4
Special school
5
Home tuition
6
Training centre (occupational centre)
7
No centre or school possible
8
Other (Specify)
0
Insufficient information
Other
SUMMARY OF ABNORMAL CONDITIONS
Please record any abnormal conditions under the appropriate headings. (Vision, speech and hearing have been assessed in their respective sections.)
-

1 - None

2 - Present but no Handicap

3 - Degree of handicap: Slight

4 - Degree of handicap: Moderate

5 - Degree of handicap: Severe

0 - Don't know

General motor handicap
Disfiguring condition
Mental retardation
Emotional maladjustment
Head and neck
Upper limb
Lower limb
Spine
Respiratory system
Alimentary system
Urogenital system
Heart
Blood, etc.
Skin
Epilepsy
Other C.N.S. condition
Diabetes

Please record any abnormal conditions under the appropriate headings. (Vision, speech and hearing have been assessed in their respective sections.) Any other conditions (Specify)

1
None
2
Present but no Handicap
3
Degree of handicap: Slight
4
Degree of handicap: Moderate
5
Degree of handicap: Severe
0
Don't know
Other

Please define any conditions recorded on this page

Generic text
END OF QUESTIONNAIRE
Would the medical examiner please thank the mother, if she is present, and glance over the questionnaire to check that:
(i) only one number in each box has been ringed;
and (ii) no question has been left unanswered (except, where appropriate, the medical history questions on pages 4, 6, 8).
End

ncds_65_mq

STRICTLY CONFIDENTIAL
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
SPONSORS:
Institute of Child Health, University of London
National Birthday Trust Fund
National Bureau for Co-operation in Child Care
National Foundation for Education Research in England and Wales
IN COLLABORATION WITH:
ENGLAND AND WALES
Association of Chief Education Officers
Society of Medical Officers of Health
Association of Directors of Education
Association of School Medical and Dental Officers
CHAIRMAN OF CONSULTATIVE COMMITTEE: Sir Lionel Russell, C.B.E., M.A.
CO-CHAIRMEN OF STEERING COMMITTEE:
H. L. Elvin, M.A.
W. D. Wall, B.A., Ph.D.
CO-DIRECTORS:
Neville R. Butler, M.D., M.R.C.P, D.C.H.
Mrs. M. L. Kellmor Pringle, B.A., Ph.D., Dip. Ed. Psych.
SENIOR RESEARCH OFFICER: R. Davie, B.A.
SENIOR MEDICAL OFFICER: M. J. Ball, B.Sc., M.B., B.S., D.P.H.
MEDICAL QUESTIONNAIRE
Local Authority Code Number
Local Authority Code Number
Child's Code Number
Child's Code Number
CHILD'S NAME (Surname)
Generic text
CHILD'S NAME (Christian Names)
Generic text
SEX
1
Boy
2
Girl
DATE OF BIRTH
Date of birth
ADDRESS OF MEDICAL EXAMINATION
Generic text
DATE OF MEDICAL EXAMINATION
Generic date
NAME OF MEDICAL EXAMINER
Generic text
DESIGNATION
Generic text
INTRODUCTORY NOTES
The Purpose of the Study
Shortly after their birth, all these children were the subject of a comprehensive investigation into the circumstances relating to the mother and child, the pregnancy and the birth. The results of this study published in the Perinatal Mortality Survey have already had a world-wide influence, and it is hoped that the many doctors and midwives who were involved feel that their efforts have been fully justified.
The National Child Development Study is a logical extension of the original investigation to the growing child. Not only is there the need to assess the present physical, educational and emotional status of the child population, but for the first time there is an opportunity to relate these assessments to the existing obstetric and social data of this large national sample.
Considerable interest is already focussed on the major handicaps of childhood, but much remains to be discovered about the true incidence of these conditions and their aetiology. Even less is known of the incidence and cause of minor disabilities, emotional maladjustments and educational handicaps. This study will throw some light on their occurence amongst children considered "at risk" of developing handicapping conditions.
This study will also reveal the numbers of children who have been exposed to such predisposing factors, but who are nevertheless developing normally.
The Scope of the Investigation
The Study is based on information gathered from three sources.
(i) The school is assessing the child's educational progress and social adjustment and is applying some attainment tests. This aspect of the investigation is being undertaken by the Local Education Department.
(ii) The mother of the child is interviewed by a Health Visitor (in most instances) who completes a Parental Questionnaire concerning the child's early life and environment. Details of illnesses, operations and a full medical history are included in this questionnaire, and on completion it will be passed on to the doctor for reference during his examination of the child.
(iii) The Medical Questionnaire comprises a medical history and examination, tests of vision, speech and hearing, physical measurements and a urine test. It is also hoped that an Audiogram will be obtained, at a time convenient to the School Health Department.
NOTES ON THE MEDICAL QUESTIONNAIRE
The form of this questionnaire has been determined by the need to utilise modern methods of handling a large volume of data. Except where stated otherwise, each question is answered by putting a ring round the appropriate number in each box.
The following order of completion is suggested as the most practical:
With the child dressed:
(1) Front page.
(2) Medical History. N.B.: Since these questions, on pages, 4, 6, 8, are identical with pages 16, 17, 18 of the Parental Questionnaire. It is not necessary for the doctor to take a second medical history if the latter is to hand and has been answered to his satisfaction.
(3) Vision, Speech and Hearing tests.
(4) Uristix urine test.
With the child undressed:
(5) Height, Weight and Head circumference.
(6) Medical examination.
(7) Completion of questionnaire.
Is the child accompanied at this medical examination by:
1
Mother
2
Father
3
Other relative (Specify)
4
Other person (Specify)
0
Child unaccompanied
Other
Is the Parental Questionnaire in hand for reference?
1
Yes
2
No
CHILD'S HEIGHT, without shoes, to nearest inch (e.g., for 48 1/2 inches, enter 49).
Inches I
and state reason
Generic text
A few areas have been issued with pocket stadiometers.
CHILD'S HEIGHT, without shoes, to nearest centimeter (e.g. for 126 cms. enter 126).
Centimetres
CHILD'S WEIGHT, in underclothes, to nearest pound (e.g. for 53 1/2 lb. enter 54).
Pounds
and state reason
Generic text
HEAD CIRCUMFERENCE, to nearest 0.5 inch (e.g. for 20 1/2 inches enter 20.5).
Inches F
and state reason
Generic text

MEDICAL HISTORY

GENERAL

Has the child, to the mother's knowledge, any physical handicap or disabling condition? Specify
2
No
1
Yes
0
Don't know
Generic text
Does the mother consider the child to be particularly sensitive or highly strung? Specify
2
No
1
Yes
0
Don't know
Generic text

EAR, NOSE AND THROAT

Has the child had more than 3 throat and/or ear infections (with fever) in the past year?
2
No
1
Yes
0
Don't know
Has the child ever had: Hay fever or sneezing attacks
2
No
1
Yes
0
Don't know
Has the child ever had: Habitual snoring or mouth breathing
2
No
1
Yes
0
Don't know
Has the child ever had: Running ears (i.e. pus, not wax)
2
No
1
Yes
0
Don't know
Has the child ever had: Running ears (i.e. pus, not wax) No. of times in past 12 mths.
How many
Has the child ever had: Earache, without running ears
2
No
1
Yes
0
Don't know
Has the child ever had: Earache, without running ears No. of times in past 12 mths.
How many
Has the child ever had: Hearing difficulty (suspected or confirmed) Specify
Has the child ever had: Hearing difficulty (suspected or confirmed) Age
Age
Has the child ever had: Hearing difficulty (suspected or confirmed) Present now?
Generic text
Has the child ever had: Other ear trouble Specify
2
No
1
Yes
0
Don't know
Other

RESPIRATORY SYSTEM

Has the child ever had: Attacks of asthma
2
No
1
Yes
0
Don't know
Has the child ever had: Attacks of asthma No. of times in all
How many
Has the child ever had: Attacks of asthma No. of times in past 12 mths.
How many
Has the child ever had: Bronchitis with wheezing
2
No
1
Yes
0
Don't know
Has the child ever had: Bronchitis with wheezing No. of times in past 12 mths.
How many
Has the child ever had: Pneumonia
2
No
1
Yes
0
Don't know
Has the child ever had: Pneumonia At what age?
Age
Has the child ever had: Other respiratory disease Specify
2
No
1
Yes
0
Don't know
Other

C.V.S.

Has the child had: Rheumatic fever
2
No
1
Yes
0
Don't know
Has the child had: Rheumatic fever At what age?
Age
Has the child had: Chorea (St. Vitus' Dance)
2
No
1
Yes
0
Don't know
Has the child had: Chorea (St. Vitus' Dance) At what age?
Age
Has the child had: Congenital heart condition Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Parent, brother or sister with congenital heart condition Specify
2
No
1
Yes
0
Don't know
Generic text

MEDICAL EXAMINATION

GENERAL

Is there a major handicapping or disfiguring condition? (e.g. mongolism, blindness, deafness, cerebral palsy, hydrocephalus, mental retardation, etc.) Specify
2
No
1
Yes
0
Don't know
Generic text

E.N.T. AND MOUTH

Does examination reveal: Nasal obstruction Specify
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Nasal or postnasal discharge Specify
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Tonsils worthy of comment Comment
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Mouth or palate abnormality Specify
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Please add up total missing, filled and carious teeth (e.g. for 7 enter 07)
How many
Does examination reveal: Have any permanent incisors appeared?
2
No
1
Yes
0
Don't know
Does examination reveal: Enlarged cervical glands Specify
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Signs of past or present otitis media (if drum obscured, ring "0" Specify
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Deformity of external ear Specify
2
No
1
Yes
0
Don't know
Generic text
Does examination reveal: Deformity of external ear R. or L.
Generic text
Does examination reveal: Other ear condition Specify
2
No
1
Yes
0
Don't know
Other

R.S.

Abnormal signs in lungs Specify
2
No
1
Yes
0
Don't know
Generic text
Abnormal chest shape Specify
2
No
1
Yes
0
Don't know
Generic text
Other respiratory condition Specify
2
No
1
Yes
0
Don't know
Other

C.V.S.

Pathological heart condition Specify
2
No
1
Yes
0
Don't know
Generic text
Other heart murmur Specify
2
No
1
Yes
0
Don't know
Other
Any other sign of heart disease (e.g. clubbing, cyanosis, etc.) Specify
2
No
1
Yes
0
Don't know
Other

MEDICAL HISTORY

ALIMENTARY AND UROGENITAL SYSTEMS

Has the child ever been/or had: Periodic vomiting or bilious attacks
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Periodic vomiting or bilious attacks No. of times in past 12 mths.
How many
Has the child ever been/or had: Periodic abdominal pain
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Periodic abdominal pain No. of times in past 12 mths.
How many
Has the child ever been/or had: Recurrent mouth ulcers
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Hernia of any sort
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Hernia of any sort Site
Generic text
Has the child ever been/or had: Other serious digestive, bowel or alimentary disorder Specify
2
No
1
Yes
0
Don't know
Other
Has the child ever been/or had: Infection in the urine (requiring medical treatment)
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Infection in the urine (requiring medical treatment) No. of times in all
How many
Has the child ever been/or had: Infection in the urine (requiring medical treatment) No. of times in past 12 mths.
How many
Has the child ever been/or had: Wet by day after 3 years of age (Ignore occasional mishaps)
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Wet by day after 3 years of age (Ignore occasional mishaps) How often in past 12 mths.
How many
Has the child ever been/or had: Wet by night after 5 years of age (Ignore occasional mishaps)
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Wet by night after 5 years of age (Ignore occasional mishaps) How often in past 12 mths.
How many
Has the child ever been/or had: Soiled by day after 4 years of age (Ignore occasional mishaps)
2
No
1
Yes
0
Don't know
Has the child ever been/or had: Soiled by day after 4 years of age (Ignore occasional mishaps) How often in past 12 mths.
How many
Has the child ever been/or had: Nephritis or other kidney or U-G disorder Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child ever been/or had: Nephritis or other kidney or U-G disorder Age
Age
Has the child ever been/or had: Parent, brother or sister with disorder of alimentary or U-G tract Specify
2
No
1
Yes
0
Don't know
Generic text

METABOLISM AND BLOOD

Is there a history of: Sugar diabetes
2
No
1
Yes
0
Don't know
Is there a history of: Sugar diabetes Age of onset
Age
Is there a history of: Any diabetes in parents, brothers or sisters Specify
2
No
1
Yes
0
Don't know
Generic text
Is there a history of: Any thyroid, pituitary or adrenal gland disorder Specify
2
No
1
Yes
0
Don't know
Generic text
Is there a history of: Any blood disorder Specify
2
No
1
Yes
0
Don't know
Generic text

SKIN

Is there a history of: Eczema in the first year
2
No
1
Yes
0
Don't know
Is there a history of: Eczema in the first year Month of onset
Generic text
Is there a history of: Eczema in the first year Sites
Generic text
Is there a history of: Eczema after the first year
2
No
1
Yes
0
Don't know
Is there a history of: Eczema after the first year Any present now?
Generic text
Is there a history of: Eczema after the first year Sites
Generic text
Is there a history of: "Strawberry marks" (raised vascular naevi)
2
No
1
Yes
0
Don't know
Is there a history of: "Strawberry marks" (raised vascular naevi) Age
Age
Is there a history of: "Strawberry marks" (raised vascular naevi) Site
Generic text
Is there a history of: "Port wine stains" (flat vascular naevi)
2
No
1
Yes
0
Don't know
Is there a history of: "Port wine stains" (flat vascular naevi) Age
Age
Is there a history of: "Port wine stains" (flat vascular naevi) Site
Generic text
Is there a history of: Other skin condition, including hair or nail disorder Specify
2
No
1
Yes
0
Don't know
Other

MEDICAL EXAMINATION

ALIMENTARY AND UROGENITAL SYSTEMS

On examination, has the child: Inguinal hernia
2
No
1
Yes
0
Don't know
On examination, has the child: Inguinal hernia R. or L.
Generic text
On examination, has the child: Other hernia Specify
2
No
1
Yes
0
Don't know
Other
On examination, has the child: Urinary incontinence
2
No
1
Yes
0
Don't know
On examination, has the child: Partially or undescended testes
2
No
1
Yes
0
Don't know
On examination, has the child: Partially or undescended testes Specify R. or L. (count retractile testes as normal)
Generic text
On examination, has the child: Been circumcised
2
No
1
Yes
0
Don't know
On examination, has the child: Other U-G abnormality Specify
2
No
1
Yes
0
Don't know
Other
On examination, has the child: Other abdominal abnormality Specify
2
No
1
Yes
0
Don't know
Other

SKIN, BLOOD, Etc.

On examination is there: Bruising or petechiae Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Any lymph gland enlargement Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Eczema
2
No
1
Yes
0
Don't know
On examination is there: Eczema Sites
Generic text
On examination is there: Eczema Severity
Generic text
On examination is there: Birthmarks
2
No
1
Yes
0
Don't know
On examination is there: Birthmarks Sites
Generic text
On examination is there: Other skin condition, including hair or nail disorder Specify
2
No
1
Yes
0
Don't know
Other

URISTIX URINE TEST

Instructions:
Dip test end of strip in urine and remove imediately.
Compare colour of tip with protein colour chart at once
1
Negative (yellow)
2
Trace
3
Positive (green)
0
Don't know or not tested
Observe colour of band (glucose) after 10 seconds
1
Negative (red)
2
Positive (purple)
0
Don't know or not tested

MEDICAL HISTORY

C.N.S. and SKELETAL SYSTEM

Has the child had: A fit or convulsion in the first year of life
2
No
1
Yes
0
Don't know
Has the child had: A fit or convulsion in the first year of life How many in first year
How many
Has the child had: A fit or convulsion in the first year of life Age at first fit
Age
Has the child had: A fit or convulsion after the first year
2
No
1
Yes
0
Don't know
Has the child had: A fit or convulsion after the first year No. of times in past 12 mths.
How many
Has the child had: A fit or convulsion after the first year Total No. of fits
How many
Has the child had: Petit mal or "blank spells"
2
No
1
Yes
0
Don't know
Has the child had: Petit mal or "blank spells" Age at onset
Age
Has the child had: Petit mal or "blank spells" No. of times last year
How many
Any drug treatment for conditions (a), (b), (c)?
Generic text
Has the child had: Frequent headaches or migraine
2
No
1
Yes
0
Don't know
Has the child had: Frequent headaches or migraine No. of times in past 12 mths.
How many
Has the child had: Travel Sickness
2
No
1
Yes
0
Don't know
Has the child had: Travel Sickness Age
Age
Has the child had: Tics or habit spasms Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Tics or habit spasms Any in past 12 mths?
Generic text
Has the child had: Breath holding, head banging or "rocking" Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Breath holding, head banging or "rocking" At what age?
Age
Has the child had: Concussion or head injury (with unconsciousness) Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Concussion or head injury (with unconsciousness) Age
Age
Has the child had: Unusual size or shape of skull Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Any spinal trouble Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Congenital dislocation of hip
2
No
1
Yes
0
Don't know
Has the child had: Congenital dislocation of hip R. or L. or both?
Generic text
Has the child had: Talipes Specify type
2
No
1
Yes
0
Don't know
Generic text
Has the child had: Talipes R. or L. or both
Generic text
Has the child had: Any fractures
2
No
1
Yes
0
Don't know
Has the child had: Any fractures Site(s)
Generic text
Has the child had: Any fractures Age(s)
Generic text
Has the child had: Any other bone or joint disorder Specify
2
No
1
Yes
0
Don't know
Other
Has the child had: Has any parent, brother or sister had a fit or convulsion Specify
2
No
1
Yes
0
Don't know
Generic text

LATERALITY

Does the mother think the child is:
1
Right-handed
2
Left-handed
3
Mixed R. and L.
0
Don't know

VISION

Has the child ever had: Squint or suspected squint Specify
2
No
1
Yes
0
Don't know
Generic text
Has the child ever had: Squint or suspected squint Age
Age
Has the child ever had: Squint or suspected squint Present now?
Generic text
Has the child ever had: Any other eye trouble Specify
2
No
1
Yes
0
Don't know
Other
Has the child ever had: Have glasses been prescribed?
2
No
1
Yes
0
Don't know
Has the child ever had: Have glasses been prescribed? At what age?
Age
Has the child ever had: Have glasses been prescribed? Reason
Generic text

MEDICAL EXAMINATION

C.N.S. AND SKELETAL

On examination is there: Cerebral palsy
1
No
2
Spastic all four limbs.
3
Spastic hemiplegia.
4
Spastic monoplegia-upper limb.
5
Spastic monoplegia-lower limb.
6
Spastic both upper limbs.
7
Spastic both lower libs.
8
Athetosis and spasticity.
9
Athetosis alone.
X
Other (Specify)
Other
On examination is there: Tics or habit spasms Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Congenital upper limb defect (check symmetry of hands) Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Any malfunction of upper limb Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Skull deformity Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Spina bifida Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Other spinal disorder Specify
2
No
1
Yes
0
Don't know
Other
On examination is there: Congenital lower limb defect (Check symmetry effect) Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Talipes
2
No
1
Yes
0
Don't know
On examination is there: Talipes Type
Generic text
On examination is there: Talipes R. or L. or both
Generic text
On examination is there: Any malfunction of lower limb Specify
2
No
1
Yes
0
Don't know
Generic text
On examination is there: Other neurological or skeletal disorder Specify
2
No
1
Yes
0
Don't know
Other

LATERALITY TESTS

Please ask the child to carry out these tasks, and observe which hand/foot/eye is used.
Hand: Throw a crumpled paper ball. Draw a cross.
1
Only R. hand used
2
Only L. hand used
3
Both R. and L. hand used
0
Could not test
Foot: Kick crumpled paper ball. Hop on one leg.
1
Only R. foot used
2
Only L. foot used
3
Both R. and L. foot used
0
Could not test
Eye: Look through rolled paper tube. Look through hole in a card.
1
Only R. eye used
2
Only L. eye used
3
Both R. and L. eye used
0
Could not test
and state reason at foot of page.
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VISION TEST

(1) Test at exactly 20 ft. with a standard Snellen chart of block capitals without seriphs.
(2) Hang the chart in a good light, level with the child's eyes, and free from glare.
(3) Please occlude the other eye efficiently without pressing on the eyeball.
(4) If the child does not know his letters and also gives an unsatisfactory response with the "E test", try again with the Snellen chart asking the child to "draw the letters in the air". If this fails, try a picture card.
(This order of procedure is recommended to avoid diagnosing a child with a spatio-visual difficulty as having a visual defect).
RESULT: Without glasses: R. Eye
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1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
RESULT: Without glasses: L. Eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
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RESULT: With glasses: R. Eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
0
0
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RESULT: With glasses: L. Eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
over 6/60 or blind
9
Unable to test Reason
0
0
Generic text
Is there evidence of: Squint
2
No
1
Yes
0
Don't know
Is there evidence of: Squint Specify R. or L.
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Is there evidence of: Squint Type
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Is there evidence of: Latent squint (cover test and "follow finger")
2
No
1
Yes
0
Don't know
Is there evidence of: Latent squint (cover test and "follow finger") Specify R. or L.
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Is there evidence of: Latent squint (cover test and "follow finger") Type
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Is there evidence of: Any other eye condition affecting vision Specify
2
No
1
Yes
0
Don't know
Other
Is there evidence of: Any other eye condition not affecting vision Sepcify
2
No
1
Yes
0
Don't know
Other
ASSESSMENT
1
Normal vision
2
Visual defect but no handicap to normal schooling and everyday activities
3
Can manage ordinary school books only with difficulty
4
Requires special school books and/or special visual aids
5
Blind, or vision insufficient to use special school books
0
Don't know, or unable to assess
ASSESSMENT Reason
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SPEECH TEST

(1) Position the child close to, and facing you.
(2) Please explain that you would like the test sentences repeated after you.
(3) Use a natural voice and observe the child's face during the replies.
(4) The sentences may be repeated if necessary.
(5) Please underline any mispronounced words (dropped aitches may be ignored) and record the total at the end.
and state reason ...)
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Test sentences: Carol threaded a needle with wool. She mended her sister's frock. Roger grasped a bundle of sticks. Eating porridge gives him strength. My brother rode his bicycle to school. Phillip had scrambled eggs for breakfast. Total mispronounced words (e.g. for 8 enter 08).
How many
Is there any stammer?
1
No
2
slight
3
moderate
4
severe
0
Don't know
Assessment of intelligibility of speech:
1
Speech fully intelligible
2
Almost all words are intelligible
3
Many words are unintelligible
4
All or almost all words are unintelligible
0
Don't know or unable to test (Reason)
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HEARING TEST

(1) Conditions should be reasonably quiet.
(2) Position the child 10 feet away, with the ear under test towards you and the child's finger occluding the other ear.
(3) Ask the child to repeat each test word after you.
(4) The words should be spoken in a quiet conversational voice (not whispered), giving plenty of time for each reply.
(5) Please underline incorrect responses and record the totals.
(6) The assistance of a second person is desirable to hear the replies.
and state reason below.)
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Right Ear. Test words: shoes horse cart seat cup frock cat bike face chick fish ship Total incorrect responses
Response
Left Ear. Test words: spoon ball star feet bus sock hat knife cake pig dish ship Total incorrect responses
Response
Assessment of hearing:
1
Normal hearing
2
Some impairment of hearing (include those corrected by wearing a hearing aid)
3
Understanding of speech impaired (even with a hearing aid)
4
Speech not understood, even with a hearing aid and raised voice
0
Don't know, or unable to test
Assessment of hearing: Reason
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Has the child been formally "ascertained as in need of special educational treatment"? (If uncertain about this or the following questions, please check with P.S.M.O.) If "Yes", specify category:
1
No
0
Don't know
2
Blind
3
Partially sighted
4
Deaf
5
Partially hearing
6
Educationally subnormal
7
Epileptic
8
Maladjusted
9
Physically handicapped
X
Speech defect
Y
Delicate
Is the child receiving special educational treatment in a special school?
2
No
1
Yes
0
Don't know
specify for which handicap
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Or in a special teaching unit?
2
No
1
Yes
0
Don't know
specify for which handicap
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Is the child likely to be considered for a special school?
2
No
1
Yes
0
Don't know
specify for which handicap
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Irrespective of local facilities, which of the following would you consider most suited to the child's educational needs?
1
Ordinary school
2
Ordinary school with remedial class or extra teaching help (for educational or mental backwardness, etc.)
3
Ordinary school with specially equipped teaching unit (for part sighted, part hearing, etc.)
4
Special school
5
Home tuition
6
Training centre (occupational centre)
7
No centre or school possible
8
Other (Specify)
0
Insufficient information
Other

SUMMARY OF ABNORMAL CONDITIONS

Please record any abnormal conditions under the appropriate headings. (Vision, speech and hearing have been assessed in their respective sections.)

-

1 - None

2 - Present but no Handicap

3 - Degree of handicap: Slight

4 - Degree of handicap: Moderate

5 - Degree of handicap: Severe

0 - Don't know

General motor handicap
Disfiguring condition
Mental retardation
Emotional maladjustment
Head and neck
Upper limb
Lower limb
Spine
Respiratory system
Alimentary system
Urogenital system
Heart
Blood, etc.
Skin
Epilepsy
Other C.N.S. condition
Diabetes
Please record any abnormal conditions under the appropriate headings. (Vision, speech and hearing have been assessed in their respective sections.) Any other conditions (Specify)
1
None
2
Present but no Handicap
3
Degree of handicap: Slight
4
Degree of handicap: Moderate
5
Degree of handicap: Severe
0
Don't know
Other
Please define any conditions recorded on this page
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END OF QUESTIONNAIRE
Would the medical examiner please thank the mother, if she is present, and glance over the questionnaire to check that:
(i) only one number in each box has been ringed;
and (ii) no question has been left unanswered (except, where appropriate, the medical history questions on pages 4, 6, 8).
Name

NCDS Age 7 Medical Questionnaire