Screening/Other Procedures  Reason  Venue  Age  

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  
4  
5 
Where does this study teenager live and what type of school does he/she attend?
Tick one box only
Has a decision been reached by a local education authority that the teenager is in need of special education help/provision?
Tick one box
In the light of your clinical examination and the records you have seen, do you consider that there is evidence of any current hearing loss?
Tick one box only
Answer (a)(r) and tick all that apply on each line
  

1  Yes, in past 12 months 2  Yes, previous to past 12 months 3  Yes, but age not known 4  No, never 5  Not known 

Recurrent sore throats (3 or more in past year)  
Middle ear infection/glue ear  
Any hearing loss, perceptive or conductive  
Eczema  
Hay Fever  
Asthma  
Wheezy bronchitis  
Bronchitis  
Pneumonia  
Pathological heart condition  
Recurrent abdominal pain  
Inguinal hernia  
Urinary infection  
Wet bed more than occasionally since 10 years of age  
Wet pants in daytime more than occasionally since 10 years of age  
Soiled pants at any time since 10 years of age 
Has this teenager ever had any of the following conditions? Any other significant illness or disability (please specify (i) ... (ii) ... (iii) ...)
Answer (a)(r) and tick all that apply on each line
Tick each line (a)  (f), and tick one box on each line
DISTANT VISUAL ACUITY  

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

Crude distant vision without glasses (test all teenagers): Right eye  
Crude distant vision without glasses (test all teenagers): Left eye  
Distant vision, wearing glasses/contacts: Right eye  
Distant vision, wearing glasses/contacts: Left eye 
In the light of your examination and the records you have seen, would you consider that there is any current visual defect, and does it result in interference with normal schooling or everyday functioning?
Tick one box only
Answer (a)(o) and tick one box per line
  If present, describe signs. What is diagnosis?  

1  Not present 2  Yes present Generic text1  Not present 2  Yes present Generic text 
1  Not present 2  Yes present Generic text1  Not present 2  Yes present Generic text 

Abnormality of face or general disfiguration  
Skin abnormality  
Upper respiratory abnormality  
Abnormal respiratory signs/conditions  
Cardiovascular abnormality  
Gastrointestinal abnormality  
Urogenital tract abnormality  
Neurological abnormality  
Musculoskeletal abnormality  
Endocrine abnormality  
Blood or lymphatic abnormality  
Behavioural or emotional problems  
Mental handicap  
Other abnormal condition(s) or syndrome(s) 
Answer (a)(e) and tick one box on each line
Answer (a)(h) and tick one box on each line.
Nature of problem/defect/handicap    

1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text 
1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text 

1  
2  
3  
4  
5  
6 
ENTER IN THIS SPACE DETAILS OF CLINICAL PROGRESS AND MAJOR FINDINGS ON ANY DEFECT, DISABILITY OR HANDICAPPING CONDITION(S).
See questions B2 & 3. Please also append here or send to us any available copies of relevant child health reports and/or special educational documents relating to such condition(s).
If carried out, please record results below for air conduction and bone conduction.
250  500  1000  2000  4000  8000  

1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 

10  
0  
10  
20  
30  
40  
50  
60  
70  
80  
90  
90+ 
If carried out, please record results below for air conduction and bone conduction.
250  500  1000  2000  4000  8000  

1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 

10  
0  
10  
20  
30  
40  
50  
60  
70  
80  
90  
90+ 
bcs_86_me
SECTION 1A. USE OF SERVICES
What screening or preventive procedures have been carried out since study teenager was 10 years old? (include tests, immunisations, screening, check ups)
Screening/Other Procedures  Reason  Venue  Age  

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  
4  
5 
SECTION 1B. DISABILITIES
please list conditions in chronological order of appearance on records, starting with earliest illness, developmental problem or handicap diagnosed.
Diagnosis  Age first recorded  Disposal  

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  
5 
SECTION 2A. MORBIDITY AND SPECIAL SENSES
Has this teenager ever had any of the following conditions?
  

1  Yes, in past 12 months 2  Yes, previous to past 12 months 3  Yes, but age not known 4  No, never 5  Not known 

Recurrent sore throats (3 or more in past year)  
Middle ear infection/glue ear  
Any hearing loss, perceptive or conductive  
Eczema  
Hay Fever  
Asthma  
Wheezy bronchitis  
Bronchitis  
Pneumonia  
Pathological heart condition  
Recurrent abdominal pain  
Inguinal hernia  
Urinary infection  
Wet bed more than occasionally since 10 years of age  
Wet pants in daytime more than occasionally since 10 years of age  
Soiled pants at any time since 10 years of age 
In your opinion is there any evidence of any of the following psychological/psychiatric problems?
  

1  No 2  Yes 3  Don't Know 

Maladjustment/behaviour disturbance  
Depression  
Aggression  
Appetite problems (e.g. Anorexia, Bulimia etc.)  
Psychosis  
Neurosis  
Suicide attempt(s) /threats 
DISTANT VISION TEST
Test at exactly 20 feet with a standard Snellen Chart of block capitals. Hang chart in good light level with teenager's eyes and free from glare. Occlude opposite eye in usual way. Test all teenagers (without glasses) first and record result separately for Right Eye and Left Eye. Then retest only teenagers with glasses/lens, wearing them.
DISTANT VISUAL ACUITY  

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

Crude distant vision without glasses (test all teenagers): Right eye  
Crude distant vision without glasses (test all teenagers): Left eye  
Distant vision, wearing glasses/contacts: Right eye  
Distant vision, wearing glasses/contacts: Left eye 
NEARVISION TEST
A SheridanGardiner nearvision chart is provided in the instruction manual. The teenager should hold it in a good light at a distance of approximately 10 inches away from the eyes. Please occlude the other eye efficiently without pressure on the eyeball. If the teenager cannot read, ask him/her to draw the letters in the air. Test near vision in all teenagers and then retest only teenagers with glasses/lenses, wearing them.
  

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

Near Vision without glasses (all teenagers): Right eye  
Near Vision without glasses (all teenagers): Left eye  
Near Vision wearing glasses/contacts: Right eye  
Near Vision wearing glasses/contacts: Left eye 
SECTION 2B. MEDICAL EXAMINATION
INITIAL PULSE RATE
HEIGHT
HEAD CIRCUMFERENCE
WEIGHT (IN UNDERCLOTHES)
BLOOD PRESSURE
Please state whether or not any abnormal condition has been found in any of the following systems in the teenager.
  If present, describe signs. What is diagnosis?  

1  Not present 2  Yes present Generic text1  Not present 2  Yes present Generic text 
1  Not present 2  Yes present Generic text1  Not present 2  Yes present Generic text 

Abnormality of face or general disfiguration  
Skin abnormality  
Upper respiratory abnormality  
Abnormal respiratory signs/conditions  
Cardiovascular abnormality  
Gastrointestinal abnormality  
Urogenital tract abnormality  
Neurological abnormality  
Musculoskeletal abnormality  
Endocrine abnormality  
Blood or lymphatic abnormality  
Behavioural or emotional problems  
Mental handicap  
Other abnormal condition(s) or syndrome(s) 
Did your examination reveal any of the following?
  If YES, please describe:  

1  No 2  Yes Generic text1  No 2  Yes Generic text 
1  No 2  Yes Generic text1  No 2  Yes Generic text 

Any scars (surgical, burns, etc.)?  
Any hernia?  
Any heart murmur?  
Undescended/ectopic testis?  
Any other abnormality not already stated in question D6? 
E. MOTOR COORDINATION TESTS
THROWING A BALL IN THE AIR
FIGURE DRAWING ON PALM OF HAND: (GRAPHESTHESIA)
Now please show the subject the 4 figures reproduced above, and ask the subject to name each one. Ask subject to close his/her eyes. Draw the first figure indicated in the following list on the right palm and ask what it was. Record whether correct, incorrect or uncertain. Continue drawing the figures on the palm indicated and record the results. Please do not repeat any part of the test.If the subject is nonverbal, ask him/her to point to the correct shape rather than name it.NOTE: DO NOT LET THE SUBJECT SEE THIS SCORE SHEET
  

1  Response correct 2  Response incorrect 3  Response uncertain 

Right palm (Figures) □  
Left palm (Figures) X  
Right palm (Figures) O  
Left palm (Figures) □  
Right palm (Figures) 3  
Left palm (Figures) O  
Right palm (Figures) X  
Left palm (Figures) 3 
STANDING ON ONE LEG: (30 SECONDS)
WALKING BACKWARDS (10 STEPS)
PULSE RATE AT END OF EXAMINATION
MEDICAL SUMMARY
List each condition below and assess the effect, if any, on the teenagers home or school progress.
Nature of problem/defect/handicap    

1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text 
1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text1  Condition present but no real disability 2  Condition resulting in slight disability 3  Condition resulting in marked disability Generic text 

1  
2  
3  
4  
5  
6 
SECTION 4. AUDIOGRAM
PURETONE AUDIOMETRY RIGHT EAR
250  500  1000  2000  4000  8000  

1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 
1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 1  O 

10  
0  
10  
20  
30  
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50  
60  
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80  
90  
90+ 
PURETONE AUDIOMETRY LEFT EAR
250  500  1000  2000  4000  8000  

1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 
1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 1  X 

10  
0  
10  
20  
30  
40  
50  
60  
70  
80  
90  
90+ 
BCS70 Age 16 Medical Examination Form