Date of examination: Height:
Name and date of birth of child: Weight:
Part 1. Obligatory.
(i.) Has the child any mental symptoms other than mental deficiency? Signs of alcoholism, etc.?
(ii.) Is there reason to think the child has any weakness, congenital or acquired? Cretinism?
(iii.) Are there any
(a) Sensory defects— sight?
hearing?
(b) Motor defects—paralysis?
tremor, etc.?
(iv.) Is the child epileptic? What symptoms are present—convulsions, vertigo, loss of consciousness? Their frequency, etc.?
(v.) Has the child adenoids?