Start
ncds_74_mq
Strictly confidential
intro i

Card No.

Card No.
intro ii

Local Authority Code Number

Local Authority Code number
intro iii

Child's Code Number

Child's Code Number
NATIONAL CHILDREN'S BUREAU
Medical examination form
NATIONAL CHILD DEVELOPMENT STUDY
(1958 Cohort)
Sponsors:
Institute of Child Health, University of London
National Birthday Trust Fund
National Foundation for Educational Research in England and Wales
In Collaboration with:
Society of Education Officers
Society of Community Medicine
Association of Directors of Education (Scotland)
Chairman of Consultative Committee:
Professor D. V Donnison BA
Chairman of Steering Committee:
W. D. Wall, BA, Ph D
Executive Co-Directors: Professor N. R. Butler MD. FRCP. DCH
R. Davie BA, Ph D. DIP.ED Psych
Mrs. M. L. Kellmor Pringle, BA, PhD, D Sc
Co-Directors: M. J. R. Healy BA J. M. Tanner MD, D Sc FRCP FRC Psych W D Wall BA, PhD
Senior Research Officer: K. R. Fogelman BA
I a(i)

Child's surname

Generic text
I a(ii)

Christian names

Generic text
I b

Sex

1
Boy
2
Girl
II a

Date of birth

Date of birth
II b

Today's date

Generic date
III

Home address

Generic text
IV

Name and address of General Practitioner

Generic text
V

Is the child accompanied by:

1
Mother/mother substitute
2
Father/father substitute
3
Both parents
4
Other adult
5
No adult, but examined
6
Child not examined, form completed from records
Please turn over the page and read the introductory notes
Section 1 Recorded History
1

Records Which records/forms are available to you as you complete this form?

1
None
2
Form 10M or School Medical Card
3
Other records (specify ...)
Other
2 a

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)?

1
No, and not likely to be required
2
No, but decision pending
3
Yes, but waiting for a place
4
Yes, receiving SET
5
Yes, received SET in past, but no longer required
6
Don't know
If you have ringed 1, 5 or 6 please proceed to section 2
If any of 2, 3 or 4 above is ringed please
qc_2_a == 2 || qc_2_a == 3 || qc_2_a == 4
2 b

Indicate into which category or categories he/she falls:

Y
Blind
X
Partially sighted
0
Deaf
1
Partially hearing
2
ESN*
3
ESN* (former SSN category)
4
*
5
Epileptic
6
Maladjusted
7
Physically handicapped
8
Speech defect
9
Delicate
*In Scotland, please ring 5 for mentally handicapped (educable), 6 for mentally handicapped (trainable) and 7 for mentally handicapped (unfit for education or training in a school or special school)
2 c

In the course of assessment was an IQ assessed and recorded?

1
Yes
2
No
3
Don't know
If yes,
qc_2_c == 1
2 c(i)

what was the result Test used

Generic text
2 c(ii)

what was the result Date of testing

Generic date
2 c(iii)

what was the result

1
IQ below 50
2
IQ 50-75
3
IQ 76-100
4
IQ 101-125
5
IQ over 125
6
Result not recorded
2 d

Does the child live:

1
At home and attends ordinary school
2
At home and attends special unit attached to ordinary school
3
At home and attends day special school
4
In a residential special school
5
In a hostel and attends day special school
6
In a hospital for the subnormal
7
In any other hospital
8
Other (please specify)
9
Don't know
Other
Section 2 Personal History
AT THIS POINT THE CHILD AND HIS/HER PARENT, IF PRESENT, SHOULD BE INVITED TO ANSWER A NUMBER OF QUESTIONS
Immunisation/Vaccination
3
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
4 a

Hospital Admission Has he/she been admitted to hospital for at least one night in the past 12 months?

1
Yes
2
No
3
Don't know
If yes,
qc_4_a == 1
4 a(i)

give presumed diagnosis(es) for each admission and name and address of hospital(s)

Generic text
4 b

Hospital accident/casualty department not resulting in Hospital Admission Has he/she attended an accident/casualty department in the past 12 months?

1
Yes
2
No
3
Don't know
If yes,
qc_4_b == 1
4 b(i)

give presumed diagnosis(es) and name and address of hospital(s)

Generic text
4 c

Hospital Outpatient attendance not resulting in Hospital Admission Has he/she attended a hospital outpatient department for consultation, investigation or treatment in the past 12 months?

1
Yes
2
No
3
Don't know
If yes,
qc_4_c == 1
4 c(i)

give presumed diagnosis(es) and name and address of hospital(s)

Generic text
4 d

General Practitioner attendance Has he/she attended a G.P. Surgery/Health Centre or been visited at home in the past 12 months?

1
No
2
Yes, once
3
Yes, twice
4
Yes, three times
5
Yes, four times
6
Yes, five or more times
7
Yes, don't know frequency
8
Don't know whether attended
If yes,
qc_4_d >= 2 && qc_4_d <= 7
4 d(i)

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

Y
Colds, sore throats or ear infections (including influenza)
X
Bronchitis or chest infections
0
Asthma or wheeziness
1
Infectious fevers
2
Gastroenteritis
3
Other infections (specify ...)
4
Abdominal pain
5
Headaches
6
Emotional problems
7
Allergic conditions
8
Acne
9
Other skin conditions (specify ...)
Other
Other 2
Y
Eye conditions
X
Accident or injury
0
Dysmenorrhea
1
Immunisation/Vaccination
2
Other reasons (specify ...)
3
Don&#39;t know
Other 3
4 e(a)

Has he/she ever been seen by a psychiatrist/psychologist: At a Child Guidance Clinic

1
Yes
2
No
3
Don&#39;t know
4 e(b)

Has he/she ever been seen by a psychiatrist/psychologist: At a Hospital (outpatient or inpatient)

1
Yes
2
No
3
Don&#39;t know
4 e(c)

Has he/she ever been seen by a psychiatrist/psychologist: Other place

1
Yes
2
No
3
Don&#39;t know
If yes, for a), b) or c)
qc_4_e_a == 1 || qc_4_e_b == 1 || qc_4_e_c == 1
4 e(i)

please give reason, age at first attendance and name and address of clinic/hospital attended

Generic text
Section 3 Medical Examination
Before completing this section please use your discretion as to whether the parent/other adult should now be thanked for attending or remain to hear the findings of your examination.
Vision
5 a

Squint Is there any evidence of a squint?

1
No
2
Yes, alternating eyes
3
Yes, right eye
4
Yes, left eye
5
Unable to test
5 b

Glasses worn Have glasses been prescribed for use at the present time?

1
No
2
Yes, and available for test
3
Yes, but not available for test
4
Don&#39;t know
If glasses prescribed
qc_5_b == 2 || qc_5_b == 3
5 c

are they for:

1
Continuous use
2
Reading and/or television only
3
Not known why prescribed
DISTANT VISION TEST
Please test distant vision using Snellen chart at 20 feet. Hang chart in a good light, level with child's eyes and free from glare. Occlude the other eye efficiently without pressing on the eyeball. Please ring the number appropriate to the lowest line correctly read.
5 d(i)

Without glasses. If unable to test ring '9' Left eye

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

Without glasses. If unable to test ring '9' Right eye

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

Retest with glasses. (If worn for distant vision and available; otherwise leave blank) Left eye

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

Retest with glasses. (If worn for distant vision and available; otherwise leave blank) Right eye

1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
Worse than 6/60 or blind
9
Unable to test
NEAR VISION
Use Near-Vision Test card provided. Ensure that the child holds the card no further away from the eye than 10ins. Occlude the opposite eye as previously. Please ring the numbers appropriate to the lowest line correctly read.
5 e(i)

Without glasses. If unable to test please ring '9' Left eye

1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 e(i)

Without glasses. If unable to test please ring '9' Right eye

1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 e(ii)

Retest with glasses. (if worn; otherwise leave blank) Left eye

1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 e(ii)

Retest with glasses. (if worn; otherwise leave blank) Right eye

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

Eye Conditions. Does he/she have any of the following conditions (please ring all that apply):

1
Cataract
2
Glaucoma
3
Coloboma
4
Microphthalmos
5
Nystagmus
6
Absent eye
7
Ptosis
8
Any other eye condition (specify ...)
9
None of the above
0
Don&#39;t know
Other
Hearing
6 a

Hearing Aid. Has a hearing aid ever been prescribed?

1
No
2
Yes
3
Don&#39;t know
CLINICAL HEARING TEST
Place the child exactly 10 feet away from the examiner sitting sideways with the untested ear occluded and further away from the examiner. Remove hearing aid, if worn. Ask the child to repeat after you each word separately, making sure that he/she cannot lip read. Speak in a quiet, medium pitched conversational voice. Test and record results below by underlining all incorrect responses and recording total.
6 b(i)

TEST WORDS Left ear Book Kind Train Last Pot Does Field Had Poor Ball Mouse Hair Big Room Can Stick Good When Wash One Three Give Saw Floor Said

Words
6 b(ii)

Right ear Good Room Last One Pot Kind Big Train Wash Mouse Said Hair Book Give When Field Stick Poor Does Saw Ball Had Can Three Floor

Words
6 c

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
Don&#39;t know
Speech
Position the child close to you and facing you. Ask him/her to read aloud the sentences on the card. This is a test of voice and articulation and NOT a test of reading so that if the child should stumble in any way or is unable to read the sentences, the examiner should read the words or phrases and ask the child to repeat them. This should rarely be necessary. Please underline any mispronounced words on your copy of the text sentences below (ignore local accents) and record the total.
7 a

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

Words
7 b

Stammer. Does he/she stammer or stutter

1
No
2
Yes, slightly
3
Yes, moderately
4
Yes, severely
5
Don&#39;t know
7 c

Assessment of Intelligibility of Speech

1
Speech is fully intelligible
2
Almost all words are intelligible
3
Many words are unintelligible
4
All or almost all words are unintelligible
5
Don&#39;t know, or unable to test
8

Height (in bare feet)

Centimetres
Feet
Inches in feet
9

Weight (in underclothes only)

Kilograms
Stones
Pounds in stone
Please read through the next series of questions, then carry out your examination to enable you to answer all of them.
10

Does he/she have any of the following skin disorders? (Please ring all that apply)

1
Psoriasis
2
Eczema
3
Acne-marked
4
Acne-mild
5
Warts-upper limbs
6
Warts-lower limbs
7
Disfiguring scars
8
Birthmarks, (specify...)
9
Other condition (specify...)
0
No skin disorders
Generic text
Other
11

Has he/she a hernia?

1
No
2
Yes, inguinal
3
Yes, femoral
4
Yes, other (specify...)
5
Don&#39;t know
6
Not examined
Other
12

Has he undescended/ectopic testicles?

1
No
2
Yes, both undescended
3
Yes, right only undescended
4
Yes, left only undescended
5
Don&#39;t know
6
Not examined
Systematic Examination
13
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&#39;t know

Generic text

1 - Yes

2 - No

3 - Don&#39;t know

Generic text

1 - Yes

2 - No

3 - Don&#39;t know

Generic text

1 - Yes

2 - No

3 - Don&#39;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
14

Do you consider he/she is:

1
Grossly obese
2
Moderately obese
3
Normal
4
Thin
5
Very thin
6
Not examined
Pubertal assessment (boys)
15 a

Has his voice broken?

1
Yes
2
No
3
Unsure
15 b

Is pubic hair:

1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
15 c

Is axillary hair:

1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
15 d

Is facial hair:

1
Absent
2
Sparse
3
Adult
Pubertal assessment (girls)
16 a

Please enter in the boxes in the margin the age, in years, at which menstruation commenced. If 'Don't know' enter X X If not yet started, enter 9 9

Age
16 b

Is breast development:

1
Absent
2
Intermediate
3
Adult
4
Not examined
16 c

Is pubic hair:

1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
16 d

Is axillary hair:

1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
Motor co-ordination tests
These tests are designed to identify the mildly clumsy or inco-ordinate child. Please test all children unless grossly handicapped or unable to comprehend the test. (Note this on the form) Practice should be limited to familiarising the child with the test. Tests (a) and (b) should be performd without shoes and socks.
17 a

STANDING HEEL TO TOE for 15 seconds Please record degree of unsteadiness:

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Unable to 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_17_a == 4 || qc_17_a == 5 || qc_17_a == 6
17 a(i)

state reason

Generic text
17 b(i)

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

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Unable to score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
17 b(ii)

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

1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Unable to 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_17_b_i >= 4 && qc_17_b_i <=6) || (qc_17_b_ii >= 4 && qc_17_b_ii <=6)
17 b(iii)

state reason

Generic text
17 c(i)

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

How many
17 c(ii)

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

How many
If test not performed or scored
qc_17_c_i == NULL || qc_17_c_ii == NULL
17 c(iii)

state reason

Generic text
17 d

SUMMARY. Do you consider from your examination and from the above tests that the child has:

1
Normal limb co-ordination
2
Mild clumsiness
3
Marked clumsiness
4
Not examined
If answer to the above is 2 or 3
qc_17_d == 2 || qc_17_d == 3
17 d(i)

does the clumsiness or inco-ordination involve:

Other
1
All limbs
2
Arms only
3
Legs only
4
Arm and leg on one side
5
One arm only
6
One leg only
7
Other combination or answer (please specify...)
ETHNIC GROUP
18

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

1
European/Caucasian
2
African/Negroid
3
Indian/Pakistani
4
Other Asian
5
Mixed Race
6
Other or unsure (specify)
Section 4 Summary of Findings
Section4 a-u
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
Section4 v

For any remarks the Medical Officer wishes to add

Generic text
Before signing the form would you mind please checking that ALL QUESTIONS have been answered and suitably recorded.
outro i

date

Generic date
Please thank the child (and parent if present) on our behalf.
THANK YOU
End

ncds_74_mq

s_intro_i
Strictly confidential
intro i
Card No.
Card No.
intro ii
Local Authority Code Number
Local Authority Code number
intro iii
Child's Code Number
Child's Code Number
s_intro_ii
NATIONAL CHILDREN'S BUREAU
s_intro_iii
Medical examination form
s_intro_iv
NATIONAL CHILD DEVELOPMENT STUDY
s_intro_v
(1958 Cohort)
s_intro_vi
Sponsors:
s_intro_vii
Institute of Child Health, University of London
s_intro_viii
National Birthday Trust Fund
s_intro_ix
National Foundation for Educational Research in England and Wales
s_intro_x
In Collaboration with:
s_intro_xi
Society of Education Officers
s_intro_xii
Society of Community Medicine
s_intro_xiii
Association of Directors of Education (Scotland)
s_intro_xiv
Chairman of Consultative Committee:
s_intro_xv
Professor D. V Donnison BA
s_intro_xvi
Chairman of Steering Committee:
s_intro_xvii
W. D. Wall, BA, Ph D
s_intro_xviii
Executive Co-Directors: Professor N. R. Butler MD. FRCP. DCH
s_intro_xix
R. Davie BA, Ph D. DIP.ED Psych
s_intro_xx
Mrs. M. L. Kellmor Pringle, BA, PhD, D Sc
s_intro_xxi
Co-Directors: M. J. R. Healy BA J. M. Tanner MD, D Sc FRCP FRC Psych W D Wall BA, PhD
s_intro_xxii
Senior Research Officer: K. R. Fogelman BA
I a(i)
Child's surname
Generic text
I a(ii)
Christian names
Generic text
I b
Sex
1
Boy
2
Girl
II a
Date of birth
Date of birth
II b
Today's date
Generic date
III
Home address
Generic text
IV
Name and address of General Practitioner
Generic text
V
Is the child accompanied by:
1
Mother/mother substitute
2
Father/father substitute
3
Both parents
4
Other adult
5
No adult, but examined
6
Child not examined, form completed from records
s_Section1RecordedHistory_i
Please turn over the page and read the introductory notes

Section 1 Recorded History

1
Records Which records/forms are available to you as you complete this form?
1
None
2
Form 10M or School Medical Card
3
Other records (specify ...)
Other
2 a
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)?
1
No, and not likely to be required
2
No, but decision pending
3
Yes, but waiting for a place
4
Yes, receiving SET
5
Yes, received SET in past, but no longer required
6
Don&#39;t know
s_q2a
If you have ringed 1, 5 or 6 please proceed to section 2
2 b
Indicate into which category or categories he/she falls:
Y
Blind
X
Partially sighted
0
Deaf
1
Partially hearing
2
ESN*
3
ESN* (former SSN category)
4
*
5
Epileptic
6
Maladjusted
7
Physically handicapped
8
Speech defect
9
Delicate
If any of 2, 3 or 4 above is ringed please
s_q2b
*In Scotland, please ring 5 for mentally handicapped (educable), 6 for mentally handicapped (trainable) and 7 for mentally handicapped (unfit for education or training in a school or special school)
If any of 2, 3 or 4 above is ringed please
2 c
In the course of assessment was an IQ assessed and recorded?
1
Yes
2
No
3
Don&#39;t know
If any of 2, 3 or 4 above is ringed please
2 c(i)
what was the result Test used
Generic text
If any of 2, 3 or 4 above is ringed please
If yes,
2 c(ii)
what was the result Date of testing
Generic date
If any of 2, 3 or 4 above is ringed please
If yes,
2 c(iii)
what was the result
1
IQ below 50
2
IQ 50-75
3
IQ 76-100
4
IQ 101-125
5
IQ over 125
6
Result not recorded
If any of 2, 3 or 4 above is ringed please
If yes,
2 d
Does the child live:
1
At home and attends ordinary school
2
At home and attends special unit attached to ordinary school
3
At home and attends day special school
4
In a residential special school
5
In a hostel and attends day special school
6
In a hospital for the subnormal
7
In any other hospital
8
Other (please specify)
9
Don&#39;t know
Other
If any of 2, 3 or 4 above is ringed please

Section 2 Personal History

s_Section2PersonalHistory_i
AT THIS POINT THE CHILD AND HIS/HER PARENT, IF PRESENT, SHOULD BE INVITED TO ANSWER A NUMBER OF QUESTIONS

Immunisation/Vaccination

3

Has he/she been immunised/vaccinated against the following (please ring appropriate number in each case)?

-

1 - Yes

2 - No

3 - Don&#39;t know

1 - Yes

2 - No

3 - Don&#39;t know
Tuberculosis (BCG)
Rubella
Smallpox

Recent Illness

4 a
Hospital Admission Has he/she been admitted to hospital for at least one night in the past 12 months?
1
Yes
2
No
3
Don&#39;t know
4 a(i)
give presumed diagnosis(es) for each admission and name and address of hospital(s)
Generic text
If yes,
4 b
Hospital accident/casualty department not resulting in Hospital Admission Has he/she attended an accident/casualty department in the past 12 months?
1
Yes
2
No
3
Don&#39;t know
4 b(i)
give presumed diagnosis(es) and name and address of hospital(s)
Generic text
If yes,
4 c
Hospital Outpatient attendance not resulting in Hospital Admission Has he/she attended a hospital outpatient department for consultation, investigation or treatment in the past 12 months?
1
Yes
2
No
3
Don&#39;t know
4 c(i)
give presumed diagnosis(es) and name and address of hospital(s)
Generic text
If yes,
4 d
General Practitioner attendance Has he/she attended a G.P. Surgery/Health Centre or been visited at home in the past 12 months?
1
No
2
Yes, once
3
Yes, twice
4
Yes, three times
5
Yes, four times
6
Yes, five or more times
7
Yes, don&#39;t know frequency
8
Don&#39;t know whether attended
4 d(i)
for which of the following reasons (please ring all that apply):
Y
Colds, sore throats or ear infections (including influenza)
X
Bronchitis or chest infections
0
Asthma or wheeziness
1
Infectious fevers
2
Gastroenteritis
3
Other infections (specify ...)
4
Abdominal pain
5
Headaches
6
Emotional problems
7
Allergic conditions
8
Acne
9
Other skin conditions (specify ...)
Other
Other 2
Y
Eye conditions
X
Accident or injury
0
Dysmenorrhea
1
Immunisation/Vaccination
2
Other reasons (specify ...)
3
Don&#39;t know
Other 3
If yes,
4 e(a)
Has he/she ever been seen by a psychiatrist/psychologist: At a Child Guidance Clinic
1
Yes
2
No
3
Don&#39;t know
4 e(b)
Has he/she ever been seen by a psychiatrist/psychologist: At a Hospital (outpatient or inpatient)
1
Yes
2
No
3
Don&#39;t know
4 e(c)
Has he/she ever been seen by a psychiatrist/psychologist: Other place
1
Yes
2
No
3
Don&#39;t know
4 e(i)
please give reason, age at first attendance and name and address of clinic/hospital attended
Generic text
If yes, for a), b) or c)

Section 3 Medical Examination

s_Section3MedicalExamination_i
Before completing this section please use your discretion as to whether the parent/other adult should now be thanked for attending or remain to hear the findings of your examination.

Vision

5 a
Squint Is there any evidence of a squint?
1
No
2
Yes, alternating eyes
3
Yes, right eye
4
Yes, left eye
5
Unable to test
5 b
Glasses worn Have glasses been prescribed for use at the present time?
1
No
2
Yes, and available for test
3
Yes, but not available for test
4
Don&#39;t know
5 c
are they for:
1
Continuous use
2
Reading and/or television only
3
Not known why prescribed
If glasses prescribed

DISTANT VISION TEST

s_DISTANTVISIONTEST_i
Please test distant vision using Snellen chart at 20 feet. Hang chart in a good light, level with child's eyes and free from glare. Occlude the other eye efficiently without pressing on the eyeball. Please ring the number appropriate to the lowest line correctly read.
5 d(i)
Without glasses. If unable to test ring '9' Left eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
Worse than 6/60 or blind
9
Unable to test
5 d(i)
Without glasses. If unable to test ring '9' Right eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
Worse than 6/60 or blind
9
Unable to test
5 d(ii)
Retest with glasses. (If worn for distant vision and available; otherwise leave blank) Left eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
Worse than 6/60 or blind
9
Unable to test
5 d(ii)
Retest with glasses. (If worn for distant vision and available; otherwise leave blank) Right eye
1
6/6
2
6/9
3
6/12
4
6/18
5
6/24
6
6/36
7
6/60
8
Worse than 6/60 or blind
9
Unable to test

NEAR VISION

s_NEARVISION_i
Use Near-Vision Test card provided. Ensure that the child holds the card no further away from the eye than 10ins. Occlude the opposite eye as previously. Please ring the numbers appropriate to the lowest line correctly read.
5 e(i)
Without glasses. If unable to test please ring '9' Left eye
1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 e(i)
Without glasses. If unable to test please ring '9' Right eye
1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 e(ii)
Retest with glasses. (if worn; otherwise leave blank) Left eye
1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 e(ii)
Retest with glasses. (if worn; otherwise leave blank) Right eye
1
6
2
9
3
12
4
18
5
24
6
36
7
60
8
Worse than 60 or blind
9
Unable to test
5 f
Eye Conditions. Does he/she have any of the following conditions (please ring all that apply):
1
Cataract
2
Glaucoma
3
Coloboma
4
Microphthalmos
5
Nystagmus
6
Absent eye
7
Ptosis
8
Any other eye condition (specify ...)
9
None of the above
0
Don&#39;t know
Other

Hearing

6 a
Hearing Aid. Has a hearing aid ever been prescribed?
1
No
2
Yes
3
Don&#39;t know

CLINICAL HEARING TEST

s_CLINICALHEARINGTEST_i
Place the child exactly 10 feet away from the examiner sitting sideways with the untested ear occluded and further away from the examiner. Remove hearing aid, if worn. Ask the child to repeat after you each word separately, making sure that he/she cannot lip read. Speak in a quiet, medium pitched conversational voice. Test and record results below by underlining all incorrect responses and recording total.
6 b(i)
TEST WORDS Left ear Book Kind Train Last Pot Does Field Had Poor Ball Mouse Hair Big Room Can Stick Good When Wash One Three Give Saw Floor Said
Words
6 b(ii)
Right ear Good Room Last One Pot Kind Big Train Wash Mouse Said Hair Book Give When Field Stick Poor Does Saw Ball Had Can Three Floor
Words
6 c
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
Don&#39;t know

Speech

s_q7a
Position the child close to you and facing you. Ask him/her to read aloud the sentences on the card. This is a test of voice and articulation and NOT a test of reading so that if the child should stumble in any way or is unable to read the sentences, the examiner should read the words or phrases and ask the child to repeat them. This should rarely be necessary. Please underline any mispronounced words on your copy of the text sentences below (ignore local accents) and record the total.
7 a
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
Words
7 b
Stammer. Does he/she stammer or stutter
1
No
2
Yes, slightly
3
Yes, moderately
4
Yes, severely
5
Don&#39;t know
7 c
Assessment of Intelligibility of Speech
1
Speech is fully intelligible
2
Almost all words are intelligible
3
Many words are unintelligible
4
All or almost all words are unintelligible
5
Don&#39;t know, or unable to test
8
Height (in bare feet)
Centimetres
Feet
Inches in feet
9
Weight (in underclothes only)
Kilograms
Stones
Pounds in stone
s_q10
Please read through the next series of questions, then carry out your examination to enable you to answer all of them.
10
Does he/she have any of the following skin disorders? (Please ring all that apply)
1
Psoriasis
2
Eczema
3
Acne-marked
4
Acne-mild
5
Warts-upper limbs
6
Warts-lower limbs
7
Disfiguring scars
8
Birthmarks, (specify...)
9
Other condition (specify...)
0
No skin disorders
Generic text
Other
11
Has he/she a hernia?
1
No
2
Yes, inguinal
3
Yes, femoral
4
Yes, other (specify...)
5
Don&#39;t know
6
Not examined
Other
12
Has he undescended/ectopic testicles?
1
No
2
Yes, both undescended
3
Yes, right only undescended
4
Yes, left only undescended
5
Don&#39;t know
6
Not examined

Systematic Examination

13

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&#39;t know

Generic text

1 - Yes

2 - No

3 - Don&#39;t know

Generic text

1 - Yes

2 - No

3 - Don&#39;t know

Generic text

1 - Yes

2 - No

3 - Don&#39;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
14
Do you consider he/she is:
1
Grossly obese
2
Moderately obese
3
Normal
4
Thin
5
Very thin
6
Not examined

Pubertal assessment (boys)

15 a
Has his voice broken?
1
Yes
2
No
3
Unsure
15 b
Is pubic hair:
1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
15 c
Is axillary hair:
1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
15 d
Is facial hair:
1
Absent
2
Sparse
3
Adult

Pubertal assessment (girls)

16 a
Please enter in the boxes in the margin the age, in years, at which menstruation commenced. If 'Don't know' enter X X If not yet started, enter 9 9
Age
16 b
Is breast development:
1
Absent
2
Intermediate
3
Adult
4
Not examined
16 c
Is pubic hair:
1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined
16 d
Is axillary hair:
1
Absent
2
Sparse
3
Intermediate
4
Adult
5
Not examined

Motor co-ordination tests

s_Motorcoordinationtests_i
These tests are designed to identify the mildly clumsy or inco-ordinate child. Please test all children unless grossly handicapped or unable to comprehend the test. (Note this on the form) Practice should be limited to familiarising the child with the test. Tests (a) and (b) should be performd without shoes and socks.
17 a
STANDING HEEL TO TOE for 15 seconds Please record degree of unsteadiness:
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Unable to score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
17 a(i)
state reason
Generic text
If test not performed or scored
17 b(i)
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
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Unable to score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
17 b(ii)
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
1
Very steady
2
Slightly unsteady
3
Very unsteady
4
Unable to score due to poor comprehension or co-operation
5
Could not test due to physical handicap
6
Test not performed for other reason
17 b(iii)
state reason
Generic text
If test not performed or scored
17 c(i)
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
How many
17 c(ii)
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
How many
17 c(iii)
state reason
Generic text
If test not performed or scored
17 d
SUMMARY. Do you consider from your examination and from the above tests that the child has:
1
Normal limb co-ordination
2
Mild clumsiness
3
Marked clumsiness
4
Not examined
17 d(i)
does the clumsiness or inco-ordination involve:
Other
1
All limbs
2
Arms only
3
Legs only
4
Arm and leg on one side
5
One arm only
6
One leg only
7
Other combination or answer (please specify...)
If answer to the above is 2 or 3

ETHNIC GROUP

18
From the child's features please place him/her in one of the following broad categories:
1
European/Caucasian
2
African/Negroid
3
Indian/Pakistani
4
Other Asian
5
Mixed Race
6
Other or unsure (specify)

Section 4 Summary of Findings

Section4 a-u

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
Section4 v
For any remarks the Medical Officer wishes to add
Generic text
s_outro_i
Before signing the form would you mind please checking that ALL QUESTIONS have been answered and suitably recorded.
outro i
date
Generic date
s_outro_ii
Please thank the child (and parent if present) on our behalf.
s_outro_iii
THANK YOU
Name

Medical Examination Form 1974