
























Has a decision been reached by the Local Education Authority that this child is in need of Special Educational Treatment (do not include 'remedial' teaching in an ordinary school unless child has been classified as ESN)?


Does the child live:




for which of the following reasons (please ring all that apply):












Speech Test. (see back of near vision card) TEST SENTENCES Number 23 has been correctly described as the shabbiest house in Churchyard Square. The gateposts were cracked and the grounds a wilderness of tangled vegetation. Matthew climbed a flight of slippery marble steps to the front door. The window curtains were drawn but he distinctly heard young voices and laughter within. A lamp in the porch was switched off abruptly when he rattled the letterbox. Enter total number of mispronounced words in the boxes in the margin. If unable to test enter X X


- | If any abnormality present Please give diagnosis, and year, name and address of any hospital attendance. | |
---|---|---|
1 - Yes 2 - No 3 - Don't know Generic text1 - Yes 2 - No 3 - Don't know Generic text |
1 - Yes 2 - No 3 - Don't know Generic text1 - Yes 2 - No 3 - Don't know Generic text |
|
Upper Respiratory Tract (ear, nose and throat) | ||
Lower Respiratory Tract | ||
Cardiovascular System | ||
Alimentary Tract | ||
Urogenital System | ||
Bones and Joints | ||
Neuromuscular, Neurological System | ||
Any other abnormality |




HOPPING The object of this test is to make a general assessment of balance and co-ordination, so please do not penalise simply because the lines are touched, if child is steady. Please record degree of unsteadiness or clumsiness. Left foot
HOPPING The object of this test is to make a general assessment of balance and co-ordination, so please do not penalise simply because the lines are touched, if child is steady. Please record degree of unsteadiness or clumsiness. Right foot
TENNIS BALL With the child standing upright and the forearm horizontal, ask him/her to bounce a tennis ball on a hard floor and catch it with the palm of the hand facing downwards. After 10 attempts with each hand, please record in the boxes the number of successful catches Right hand-number of catches
TENNIS BALL With the child standing upright and the forearm horizontal, ask him/her to bounce a tennis ball on a hard floor and catch it with the palm of the hand facing downwards. After 10 attempts with each hand, please record in the boxes the number of successful catches Left hand-number of catches


- | |
---|---|
1 - None 2 - Insufficient Information 3 - Degree of Handicap if Condition Present: No handicap 4 - Degree of Handicap if Condition Present: Slight 5 - Degree of Handicap if Condition Present: Moderate 6 - Degree of Handicap if Condition Present: Severe 7 - Degree of Handicap if Condition Present: Degree unknown |
|
General motor handicap | |
General physical abnormality | |
Mental retardation | |
Emotional/behavioural problem | |
Head and neck | |
Upper limb | |
Lower limb | |
Spine | |
Respiratory system | |
Alimentary system | |
Urogenital system | |
Heart | |
Haematological | |
Skin | |
Epilepsy | |
Other CNS condition | |
Diabetes | |
Eye condition | |
Hearing defect | |
Speech defect | |
Any other abnormal condition |



ncds_74_mq
Section 1 Recorded History
Section 2 Personal History
Immunisation/Vaccination
Has he/she been immunised/vaccinated against the following (please ring appropriate number in each case)?
- | |
---|---|
1 - Yes 2 - No 3 - Don't know 1 - Yes 2 - No 3 - Don't know |
|
Tuberculosis (BCG) | |
Rubella | |
Smallpox |
Recent Illness
Section 3 Medical Examination
Vision
DISTANT VISION TEST
NEAR VISION
Hearing
CLINICAL HEARING TEST
Speech
Systematic Examination
Is there any abnormality of the:
- | If any abnormality present Please give diagnosis, and year, name and address of any hospital attendance. | |
---|---|---|
1 - Yes 2 - No 3 - Don't know Generic text1 - Yes 2 - No 3 - Don't know Generic text |
1 - Yes 2 - No 3 - Don't know Generic text1 - Yes 2 - No 3 - Don't know Generic text |
|
Upper Respiratory Tract (ear, nose and throat) | ||
Lower Respiratory Tract | ||
Cardiovascular System | ||
Alimentary Tract | ||
Urogenital System | ||
Bones and Joints | ||
Neuromuscular, Neurological System | ||
Any other abnormality |
Pubertal assessment (boys)
Pubertal assessment (girls)
Motor co-ordination tests
ETHNIC GROUP
Section 4 Summary of Findings
Having completed the examination, would you please read the following instructions and fill in the summary table. For each category (a) to (u) below: If no abnormal condition is present, ring '1' If unable to decide whether condition present, ring '2' If condition present but will not handicap ordinary employment in future, ring '3' If the condition might handicap the child in future employment, ring '4', '5' or '6' as applicable. If the condition is present and you cannot judge the degree of severity, please ring '7'
- | |
---|---|
1 - None 2 - Insufficient Information 3 - Degree of Handicap if Condition Present: No handicap 4 - Degree of Handicap if Condition Present: Slight 5 - Degree of Handicap if Condition Present: Moderate 6 - Degree of Handicap if Condition Present: Severe 7 - Degree of Handicap if Condition Present: Degree unknown |
|
General motor handicap | |
General physical abnormality | |
Mental retardation | |
Emotional/behavioural problem | |
Head and neck | |
Upper limb | |
Lower limb | |
Spine | |
Respiratory system | |
Alimentary system | |
Urogenital system | |
Heart | |
Haematological | |
Skin | |
Epilepsy | |
Other CNS condition | |
Diabetes | |
Eye condition | |
Hearing defect | |
Speech defect | |
Any other abnormal condition |
Medical Examination Form 1974