EXAMINATION 37
File
Number
Code
Movement ______________________
Deformity_ ______________________
Mentally Slow____________________
Blindness________________________
Deafness________________________
Speech__________________________
Seizures _ _______________________
Behavior_________________________
Other_ __________________________
Future action:
Date:
Done:
______ come back again _________ _ ______
______ refer to specialist _________ _ ______
______ visit at home
_________ _ ______
______ other _________ _________ _ ______
Specific disability if known: _ __________________________________________________________________
RECORD
SHEET
1
(page 1)
CHILD’S HISTORY (First visit)
Name:________________________________________________________________ Sex:
Date of birth:________________________________ Address:_ ________________________________
Age:_ ________ Weight:_ _______ Height:________ __________________________________________
Mother:_ ___________________________________ __________________________________________
Father:_____________________________________ Telephone:________________________________
How did you learn about the program?_____________________________________________________
WHAT IS THE CHILD’S MAIN PROBLEM?_ ________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
When did it begin?____________________________ How? (Cause?)______________________________
Other problems?_ _______________________________________________________________________
Is the disability improving?__________ Getting worse?_ ________ About the same?_ ______________
Explain:________________________________________________________________________________
How do you hope your child will benefit from coming here?___________________________________
Do other family members or relatives have a similar problem?_ ___ Who?_______________________
Has the child received medical attention?______ What?_______________________________________
________________________________ Where?________________________________________________
Use any braces or other aids?______ What?_________________________________________________
Has the child used any in the past?_ ___ Explain:_____________________________________________
_______________________________________________________________________________________
How is the child’s general health?_ ________________________________________________________
Is the child fat?_______________ Very thin?____________________ Other?________________________
Hears and sees well?_ __________ Explain:__________________________________________________
Comment on the child’s developmental abilities or difficulties:
normal for age?
head control_________________________________________________________ _ _____________
use of hands_ _______________________________________________________ _ _____________
creeping or crawling__________________________________________________ _ _____________
standing, walking_ ___________________________________________________ _ _____________
play_ _______________________________________________________________ _ _____________
feeding or drinking___________________________________________________ _ _____________
toileting_____________________________________________________________ _ _____________
personal hygiene_____________________________________________________ _ _____________
dressing_ ___________________________________________________________ _ _____________
Does the child speak?____________ How much or well?____________ Began when?____________
What other things can the child do?________________________________________________________
_______________________________________________________________________________________
What things can the child not do?_ ________________________________________________________
_______________________________________________________________________________________
What new skills or abilities would you like to see your child gain?______________________________
_______________________________________________________________________________________
disabled village children