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48
The following is a cooy of the Form of Report on a mentally
deficient child as approved by the Board of Education:—
REPORT ON CHILD EXAMINED FOR MENTAL DEFICIENCY.
To the Local Education Authority for the
of
I have examined the undermentioned child for Mental Deficiency,
and have to report as follows:—
I. Name of Child (in full).
Address.
Date of Birth, and Sex.
School (if any).
II. Particulars of Home Conditions, Environment, School
Attendance, and other factors.
III. Family History (in regard to history of mental defect,
epilepsy, alcoholism, &c.).
IV. Personal History
(a) Constitutional Defects, Injury at Birth, Malnutrition,
Rickets, Congenital Syphilis, &c.
(b) Diseases of Childhood.
(c) Commencement of Teething.
(d) Walking.
(e) Speech.
V. Physical Conditions:—
(a) General (results of routine medical inspection).
(b) Special:—
(1) Speech: Defective articulation.
(2) Sight: Blindness, total or partial, errors of refraction.
(3) Hearing: Deaf-mutism, partial deafness, partial
mutism.
(4) Nose and throat : Enlarged tonsils, adenoids,
mouth breathing.
(5) Control of spinal reflexes and of salivation.
(c) Stigmata:—
(1) General retardation—Cretinoid development.
(2) Cranium—Microcephaly, hydrocephaly, asymmetry,
rickets, imperfect closure of fontanelles,
simple hea3 measurement.
(3) Hair—Double and treble vortices, wiry or supple.
(4) Face—Irregularity of features.
(5) Lower jaw—Protruding or receding.