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

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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)  

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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) *  

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

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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  

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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)  

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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  

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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) *  

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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  

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1952 Examination by the School Doctor