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  LEYTON URBAN DISTRICT COUNCIL. Medical Inspection, under Sec. 13 of the Education (Ad. Prov.) Act, 1907. MEDICAL SUMMARY SHEET.

  No. of Card	CHILD'S NAME	Sex	Age (Years and 12ths)	Sunday School or other Classes	OCCUPATION OF PARENT	No. of Children in Family	Tuberculosis in Family	Age at which Child has suffered from							Vaccination Marks	Regularity of Attendance	PHYSICAL. CONDITION.																								Absent for Illness
  																	4	5	6	7	8	9	10	11	12		13	14		15	16	17	18	19	20	21	22	23	21	25	No. of Days	Cause
  								Measles	Whooping Cough	Chicken-Pox	Scarlet Fever	Diphtheria	Clothing and Foot Gear	Height			Weight	Nutrition	Cleanliness and Condition of Skin	Teeth	Nose and Throat	External Eye Disease	Vision		Ear Disease	Hearing		Speech	Mental Condition	Heart and Circulation	Lungs	Nervous System	Tuberculosis	Rickets	Deformities, Spinal Disease	Infectious or Contagious Disease	Other Disease or Defect
  																							Right	Left		Right	Left
  							(T)	(M)	(W)	(C)	(S)	(D)