Family history: Medical-Feeble-mindedness, insanity, nervous disorder, alcoholism, tuberculosis, sickness or accident Injury to head-At birth; after birth. Acute illness-Scarlet fever, diphtheria, meningitis, convulsions, early malnutrition. Bad companions, truant, lies, cheats, steals, profane, smokes cigarettes, vicious habits. Dependable, willing and tries, good natured, affectionate. Apathetic, restless, mischievous, quarrelsome, obstinate, incorrigible, marked peculiar traits. Speech-Clear, indistinct, thick, inarticulate, fluent, slow, hesitating, mute, lisp, stammer. Gait-Normal, lively, shuffling, unsteady, clumsy. School history: Schools attended-City, country, or institution (specify). Standing Months in present grade...... Months in preceding grade...... Prospects of promotionGood, fair, poor, none. Attendance-Regular, irregular, punctual. Arithmetic-Good, fair, poor. Writing-Good, fair, poor. Spelling-Good, fair, poor. Reading-Good, fair, poor. Language-Good, fair, poor. Drawing-Good, fair, poor. Attention-Good, poor. Memory-Good, poor. Common sense. Physical condition-Height inches. Weight To the principal: Kindly see that the above form is filled out as accurately as possible. The data may be obtained from parents, children, and teachers, as well as from your personal knowledge of the case. Please underline the descriptive words applicable to this case, and return the blank as soon as possible to the city superintendent of schools. Diagnosis: Degree of mentality-Dull, backward, backward-emotive, feeble-minded, imbecile, idiot. Recommendations: Medical, social, educational, special class for backward-feeble-minded-disciplinary cases. Name.. RECORD BLANKS FOR REVISED BINET TESTS. Examined..... 1. Points to nose, eyes, mouth. 2. Repeats "It rains. I am hungry." 1st series time 20" (2 out of 3)-(a) missed train, (b) struck by playmate, etc., (c) broken something. 2d series time 20" (3 out of 5)-(a) late to school, (b) important affair, (c) forgive easier, (d) asked opinion, (e) actions v. words. 5. Sentence: Philadelphia, money, river. (Time 1′). XI. 1. Sees absurdity (3 out of 5) (time 2′): (a) Unfortunate painter, (b) three brothers, (c) locked in room, (d) railroad accident, (e) suicide. 3. Gives sixty words in three minutes (record on back). 4. Rhymes (time 1' each) (3 rhymes with each word): Day, spring, mill. 5. Puts dissected sentences together. (Time l' each): a. b. XII. 1. Repeats 2 9 6 4 37 5. 92 8 5 1 6 4. 13 9 5 8 4 7. 2. Defines charity, justice, goodness. 3. Repeats, "I saw in the street a pretty little dog. He had curly brown hair, short legs, and a long tail." 4. Resists suggestion (Lines). 1. 2. 3. 5. Problems: (a) Hanging from limb; (b) neighbor's visitors. 4. 5. 6. 4. Opposites: (1) good, (2) outside, (3) quick, (4) tall, (5) big, (6) oud, (7) white, (8) light, (9) happy, (10) false. 5. Na e and address of secretary of the board of e lucation or district clerk... 13. Nearness and height of surrounding buildings. 14. Fire escape on building... 15. Yard, for what purpose used. 16. Privy vault on pre nises.. ...; size........ .; location. condition. ......; condition. 17. Cesspool......... ... construction. 18. Any objectionable accumulation on premises or adjoining premises?.... 19. Cellar under entire building.. 20. Depth beneath ground surface....... 21. Material an I condition of cellar bottom.. 22. Number an 1 size of windows.. 23. Is cellar well lighted?... 24. Is cellar damp?........ CELLAR. PLUMBING, DRAINAGE, AND WATER-CLOSET APARTMENTS. 23. Is building connected with sewer?.. 26. Any leaks or defects noted in drains?... 27. Size and location of water-closet apartments.. 28. Material and condition of floors....... 29. Number and size of windows opening to outer air.. 30. Ventilation of apartment... 31 Cleanliness of apartment.. 32. Number and style of water-closets. 33. Are water-cla ets in good repair?.. 34. How flushed..... 35. Number and style of urinals.. 36. Are urinals in good repair?.. 37. How flushed?.... 38. Cleanliness of fixtures. 39. Any disinfectant or deodorant used in fixtures or apartment?......; kind. 40. Are there facilities for pupils to wash hands after using closets or urinals?. 62. Designate room......; grade....... .; total enrollment; greatest average attendance for any preceding month 63. Size: Length...............; width..........; height.. 64. Square feet of floor space per pupil.. 65. Cubic feet of air space per pupil... 66. Number and size of windows. 67. Percentage of light to floor space.... 68. Light enters from east, west, north, south. 69. Are there window shades to control volume of light? 70. Desks face east, west, north, south.. 71. Color and finish of ceiling and side walls. 72. Do doors s ving in or out?. 73. If swinging doors, have they plate-glass panels?.. 74. Style of desks and seats...... ......; cubic contents. 1. Are pencils and penholders distributed and collected daily?...... Are they disinfected after each collection?....... How?.. 2. Location of cloak room..... 93. Separate compartment for each pupil?.. 94. Light and ventilation of cloak room.. 95. Is approach to fire escape clear?. MEDICAL INSPECTION. 96. Name and address of medical inspector.. ..; date of appointment.. 97. Frequency of inspector's calls..... 98. Has board of education adopted rules for guidance of medical inspector?... (Procure copy if available.) 99. Are blank forms used by medical inspectors in making records?. (Procure copy if available.) 100. Number of lectures given before teachers by medical inspector during each term.. 101. Are unvaccinated pupils or teachers permitted to attend school?.... 102. Number of unvaccinated pupils in school..... .....; teachers.. 103. Are pupils or teachers residing in dwellings in which infectious disease exists excluded from school?.... 104. Are pupils and teachers required to present a written permit upon return to scho 1 after exclusion on account of infectious disease?.. Who issues permit?. 108. Method and frequency of scrubbing floors.... 10%. Method and frequency of cleaning desk tops, chairs, handrails, door knobs, and casings.. 110. Method of disinfecting schoolrooms after a case of infectious disease occurs.. performed?........ 111. Describe any appliances for disinfecting kindergarten equipment.. 112. How frequently used?.... 113. Has school a gymnasium?. 114 Any facilities for bathing?. Date...... Are there special instructors?.. ...; describe them.. ; by whom Inspector. AMERICAN SCHOOL HYGIENE ASSOCIATION. QUESTIONNAIRE. [PREPARED BY THE COMMITTEE ON THE STATUS OF MEDICAL INSPECTION OF THE AMERICAN SCHOOL HYGIENE ASSOCIATION.'] 1. Is there any organized system of medical inspection of school children in your town? 2. Does this embrace inspection of children for the detection of (a) contagious disease, and (b) remediable physical and hygienic defects? 3. Do you follow up cases of contagious disease, remediable physical defect, and hygienic imperfection? 4. What per cent of children thus followed up receive legitimate treatment by reputable physicians? 5. State the number of schools under supervision. 6. Give the total population of all schools. 7. How many schools are visited daily by the medical inspector? 8. Are parochial, private, or any other than public, supervised by the medical inspector? 9. What is the average number of children under the supervision of one inspector, and how often are the individual children seen by the inspector? 10. Does the city provide free baths in the school buildings or in other places for the use of the school children. 11. How extensively are these baths used, and what is their sanitary supervision? 12. Do the medical inspectors visit the homes of absentees to learn the reason of their absence? 13. Do the pupils provide their own writing utensils? 14. How are the materials, as pencils, paper, clay, books, etc., collected and stored in the classroom? 1 See American medical association. Committee on medical inspection of schools. Its Journal, 57: 175157, Nov. 25, 1911. $2883°-13-9 |