[This monthly report of vaccination is to be made out and forwarded to the chief medical inspector at the close of each month.] Number of previous vaccinations examined and certificates issued therefor.. M. D., Medical Inspector. To the parents of DEPARTMENT OF HEALTH, CHICAGO. (Pupil's name.) Your child (named above) is not properly protected against smallpox. It should be vaccinated at once. You owe it to your child to protect it against the most horrible of all diseases-smallpox. Either take this child to your family doctor or give your permission to have it vaccinated (free) by the school doctor. The purest vaccine will be used. Do you consent to having your child vaccinated by the school doctor. In the interest of the child's welfare kindly give permission to have a thorough examination of the child made by the school doctor. Parents can be present at the examination if they desire. BOARD OF EDUCATION, CITY OF CHICAGO. SPECIAL REPORT OF PRINCIPAL ON PUPIL RECOMMENDED FOR EXAMINATION BY THE CHILD-STUDY DEPARTMENT. To the Superintendent of Schools: Character of ease.. Parent or guardian. Name of child.. Home address.. School history: Age.. (State whether deaf, blind, crippled, backward, imbecile, or pulmonary tuberculosis.) Remarks. Forehead retreating. Foorehead narrow.. Forehead low. Facial asymmetry: Forehead......; nose....; eyes....; ears....; mouth parts. Ears deformed.. Dentition: Teeth irregular......; doubled.. serrated....; pointed....; chalky.. Palpebral fissures small. Nasal bones sunken.. Adenoidic.. Mouth breathing.. Palate: Narrow.. .; high.. ..; asymmetrical.. Tongue: Thick....; flat....; pointed....; furrowed......; papillae hypertrophied.. coated. Movement: Sluggish.. Restless. Incoordinated.. General balance relaxed. Asymmetrical posture.. Asymmetrical head balance. Overaction of frontals Corrugation..... Incoordination of eyes. Relaxed orbicularis oculi. Hand balance: Asymmetrical. Tense.. Relaxed. Drooped... Finger twitchings.. Eyelid twitchings. Tongue twitchings. Defective speech: Hesitation.. Stammering.. .; lisping.. .; stuttering.. Improper pronunciation of.. General observations on mental action: Judgment erratic......; mind wandering.. Sensitivity: Good....; fair....; poor.... Ability to reason: Good..; fair....; poor.... REMARKS AND RECOMMENDATIONS. Lordosis.. Chest sunken.. Hydrocephalic. Microcephalic. |