38 chapter 4
Is the child mentally normal?_________________________________________________
Mentally slow?_ __ How severely?__________________________________________
Why do you think so?_ ___________________________________________________
RECORD
SHEET
1
Does the child have seizures?_ _______ How often?__________________________ (page 2)
Describe:__________________________________________________________________
Takes medicine?_________ What?_ _________________________________________________________
For what?___________________________ Results (good or bad):_ _______________________________
Behavior normal for age?_________________________________________________________________
Behavioral or emotional problems?_______ Explain:___________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Goes to school?________ What year?_ ______________________________________________________
With whom does the child live?_ __________________________________________________________
Number of brothers and sisters:________ Ages:________________________ AVER AGE E A RNINGS
Father works?_________At what?_ ___________________________________ ____________________
Mother works?________At what?_ _________________________________________________________
The child seems: well-cared for?_ _______ spoiled or overprotected?___________________________
neglected?______ happy?________ self-confident?_________ withdrawn?_ _____________________
other?_ ______________________________________________________________________________
Important details of family situation:_______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What has the family done, made, or obtained to help the child function better?_ ________________
_____________________________________________________________________________________
Other observations, information or drawings:
(Use an additional sheet if necessary.)
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
History of illness Date
measles
________
chicken pox ________
whooping cough ________
other _ _____ ________
____________ ________
Vaccinations:
BCG (TB)
polio
D.P.T
Hep B
(Hepatitis B)
measles
tetanus
other
How many
Dates
Allergies
How much have you spent for your child’s disability?_ ______ For what?_ _______________________
_______________________________________________________________________________________
Were disability or complications caused by improper medical treatment or therapy?_____________
Explain:________________________________________________________________________________
FOR CHILDREN WITH PARALYSIS:
Was your child injected before becoming paralyzed?_____________________________________________
Disabled village Children