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DEPARTMENT OF HEALTH, CITY OF CHICAGO.

191..

DENTAL INSPECTOR'S DAILY REPORT.
School....

CHICAGO.
Total number examined.
Number found to have defective teeth.
Number needing immediate attentions.
General condition of teeth found: Good.

fair
Number of pupils applying for dispensary work
Remarks..

..; bad.

D. D. S.

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D. D. S.

Eraminer.

Followed up.

Nurse.

DEPARTMENT OF HEALTH, CITY OF CHICAGO.

REPORT OF VACCINATIONS. (This monthly report of vaccination is to be made out and forwarded to the chief medical inspector at

the close of each month.)
Name of school .....
Report for the month of..

191..
Number of tubes of glycerinated vaccine received during the month.
Number of tubes of glycerinated vaccine used during the month.
Total number of primary vaccinations performed (successful).
Total number of primary attempts at vaccination with failure.
Total number of revaccinations performed (successful). ..
Total number of attempts at revaccination performed with failure..
Number of previous vaccinations examined and certificates issued therefor.
Kind of vaccine used and laboratory numbers of same.

M.D.,
Medical Inspector.

DEPARTMENT OF HEALTH, CHICAGO. To the parents of

(Pupil's name.) Your child (named above) is not properly protected against small pox. 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.

Answer "Yes" or "No" here.

(Sign your name here.).. Return this card, signed, to the school-teacher. (See other side.)

DIVISION OF CHILD HYGIENE-PARENT'S CONSENT CARD. To the parents of

Address Your child attending the.... shows evidence of the following condition:

school

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.
Please sign this card and return it to the school.

C. B. YOUNG,

Commissioner of Health. Parent's signature ...

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CHILD-STUDY LABORATORY.

RECORD CARD FOR CRIPPLED CHILDREN.

Name.
Parent or guardian.
Address....
Nationality and language of home.
Place of birth.
Date..
Date of birth
Age.
School.
Name of medical examiner.
History of case.
Disposition of case.

year.
year.
years.
(Teacher

.month
month.
months.

.day. ..day. ..days

PHYSICAL CONDITION.

Vision, right eye..
Vision, left eye.
Hearing, right ear.
Hearing, left ear..
Nutrition,

Character of skin and hair...
Anaemic.....
Tongue, coated, furrowed.

Teeth, decayed, serrated, irregular.
Nature of affliction:
Tuberculosis-

1. Pulmonary...
2. Glandular..

Sinuses, character of discharging, raw, partially healed, scars. 3. Osseous and arthralgic..

Spondylitis....
Hip disease.
Knee joint.
Ankle and other forms.

Sinuses, character of-discharging, raw, partially healed, scars..
Neuroses-

1. Infantile cerebral paralysis.
2. Infantile spinal paralysis.
3. Hemiplegia....
4. Paraplegia.

Upper..

Lower..
5. Chronic hydrocephalism.

6. Pseudo-hypertrophy.
Specific.....
Injuries and deformities

MENTALITY.
School standing:

Grade.
Time in school.

Progress..
Imitation, ability to duplicate movements and sounds:

(a) Simple..

(6) Complex. Suggestibility, ability to express movements or thoughts from cues:

(a) Immediate..

(6) Remote..
Reproduction, immediate-sense memory:

(2) Movements..
(6) Objects seen.
(c) Words seen..
(d) Numerals seen.
(e) Words heard.

) Numerals heard. Perception:

Card sorting.

“A” test....
Association and comparison; translating from one sense to another:

Numeral-color association...
Numeral-symbol association.

Part-whole association..
Remarks

BOARD OF EDUCATION, CITY OF CHICAGO.

OFFICE OF SUPERINTENDENT OF SCHOOLS.
File No. .... .... Child-Study Department.

SPECIAL REPORT OF PRINCIPAL ON PUPIL RECOMMENDED FOR EXAMINATION BY

THE CHILD-STUDY DEPARTMENT.

To the Superintendent of Schools:

.School.

Character of case.

(State whether deal, blind, crippled, backward, imbecile, or pulmonary tuberculosis.)

Name of child.
Parent or guardian.
Home address.
School history:

Age.
Grade..
Time in grade.

Remarks.

(Signed)

[Data to be filled at the office of the superintendent.) Referred to district superintendent....

Date returned.

Referred to child-study department. Report of examination: By

Recommendation. Disposition...

BOARD OF EDUCATION, CITY OF CHICAGO, EDUCA

TIONAL DEPARTMENT.

No.-
CHILD-STUDY LABORATORY.
By whom referred..
Name....
Name of parent or guardian..
Address.
School...

i room. Grade.

No. of weeks in grade.
Teacher..
Date......... year.......month...... day
Date of birth, year....... month......day.
Age.. ..years....... months.....days.
Nationality and language of home.
Age of brothers and school record.
Age of sisters and school record.
Age of brothers and sisters dead.
Causes of their deaths....
Health of father.....good.. fair

-poor. Health of mother....good..... fair. -poor Age of father..

mother. Hygienic condition of home...good...fair...poor.. Garbage... ..sewerage........ noise.. Food......

Education of parents. Aesthetic and moral influence.... Family history--neurotic.. tubercular..alcoholic...

Specific. Development.-Dentition, 1st......., 2d. walking......, talking....., fontanelles trol of fundamental reflexes..

.190..

Principal.

Dato

Recommendation..

Date.

chorea......, litis......,

......., moist

Health record:
Diseases--Measles. ....., mumps......, whoop-

ing cough.... scarletina..
scarlet fever.. diphtheria.
meningitis.... epilepsy.

scrofula... tonsil

other diseases.
Accidents and operations..
General health tonus: Infancy.

child-
hood...... at present..
Nutrition.. anaemic.. ..pallor.
Skin: Dry.

oily Hair: Dry and gritty...

...... growth irregular Circulation: Hands, cold ...... ...purple..... School standing:

Best work in.... -; poorest work in..
Deportment..
Is the child lazy. inattentive dull..,
stupid..... stubborn...

untruthful......, cruel. slovenly...., excitable...., ill-tempered.... Anthropometric tests:

Net height...., height sitting...., weight....
Head measurements: Length...., breadth....,

height...., circumference...., cephalic in

dex....
Lung capacity.
Strength of grip: Right hand.

left
hand.
Motor ability: (a) Tapping rate, right hand

108........209........30s...... i left hand 103........20........30s..

...., unruly.

selfish.....

.etc.....

con

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