Name  Age  State whether cold, sore throat, cough or catarrh  

Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text  Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text  Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text  
1  
2  
3  
4 
Age at Attack  Duration of Discharge in weeks  Where treated Hos. I.P. Hos.O.P. Nursing Home Own Home  If treated at home, who gave treatment (Doctor, Nurse, other)  

AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  
1  
2  
3 
Eye Dominance.
Give this child a white quarto sheet of paper in the middle of which a hole approximately one inch in diameter has been cut. Ask him to hold the paper close to his face and look through the hole at an object about six feet away. Please note whether he uses the left or the right eye. Repeat several times.
*Cross out the one that does not apply.
Weight (in indoor clothes) ... st.  Weight (in indoor clothes) ... lbs.  Weight (in indoor clothes) *  Height (deduct height of heels if measured in shoes) ... ft.  Height (deduct height of heels if measured in shoes) ... ins.  Height (deduct height of heels if measured in shoes) *  

1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 

Mother  
Father 
Condition  Age when reported  Additional information needed  Doctor's comments  

AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  
1  
2  
3 
nshd_52_sd
FOR THOSE WHO HAVE MOVED
A. MEDICAL HISTORY
COLDS, SORE THROAT, ETC.
Please say which members of the household suffer from them (giving names and ages).
Name  Age  State whether cold, sore throat, cough or catarrh  

Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text  Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text  Generic textAgeGeneric textGeneric textAgeGeneric textAgeGeneric textGeneric text  
1  
2  
3  
4 
TONSILS
COUGHS
A_TEETH
A_HEART
A_ABDOMEN
SPECIAL SENSES
Please give the following details:
Age at Attack  Duration of Discharge in weeks  Where treated Hos. I.P. Hos.O.P. Nursing Home Own Home  If treated at home, who gave treatment (Doctor, Nurse, other)  

AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  AgeGeneric textGeneric textDuration (weeks)Generic textGeneric textDuration (weeks)AgeGeneric textGeneric textDuration (weeks)AgeDuration (weeks)Generic textAgeGeneric text  
1  
2  
3 
FITS AND CONVULSIONS
B. EXAMINATION
APPEARANCE
PHYSICAL MEASUREMENTS
NASAL PASSAGES
THROAT AND TONSILS
B_TEETH
LUNGS
B_HEART
B_ABDOMEN
MISCELLANEOUS
EARS
EYES
Visual acuity.
Without glasses  With glasses  

Generic textGeneric textGeneric textGeneric text  Generic textGeneric textGeneric textGeneric text  
Right eye  
Left eye 
LATERALITY
ASSESSMENTS
PARENTS' MEASUREMENTS
It would be of great value if the following information could be obtained about the parents of this child. It is realised that it may not be possible to get actual measurements in which case please give approximate figures.
Weight (in indoor clothes) ... st.  Weight (in indoor clothes) ... lbs.  Weight (in indoor clothes) *  Height (deduct height of heels if measured in shoes) ... ft.  Height (deduct height of heels if measured in shoes) ... ins.  Height (deduct height of heels if measured in shoes) *  

1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 
1  actual 2  estimate 1  actual 2  estimate StonesPounds in stoneFeetInches in foot1  actual 2  estimate Pounds in stoneInches in foot1  actual 2  estimate StonesFeetInches in footFeetPounds in stoneStones1  actual 2  estimate 1  actual 2  estimate Pounds in stone1  actual 2  estimate StonesInches in footFeet1  actual 2  estimate 1  actual 2  estimate Feet1  actual 2  estimate StonesPounds in stoneInches in footPounds in stoneStonesFeetInches in foot1  actual 2  estimate 1  actual 2  estimate 

Mother  
Father 
CHECK OF PAST INFORMATION
THE FOLLOWING CONDITIONS WERE REPORTED IN EARLIER SURVEYS. PLEASE CHECK THEIR ACCURACY AND SUPPLY, IF POSSIBLE, THE ADDITIONAL INFORMATION ASKED FOR.
Condition  Age when reported  Additional information needed  Doctor's comments  

AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textAgeGeneric textGeneric textAgeGeneric text  
1  
2  
3 
1952 Examination by the School Doctor