An audit of decision making at the entry medical was carried out to ascertain how doctors responded to childrens' physical, developmental and psychosocial adversity. Using specifically designed recording protocols, eleven doctors recorded their activity at 922 entry medicals over one term. The results were discussed, protocols of decision making were prepared and ten doctors re-ran the exercise assessing a further 783 over one term; one year later. The proportions discussed with headteachers, referred to agencies and selected for review varied in both data sets, and certain trends emerged. More experienced doctors were more likely to discuss vulnerabilities and did so for 18 to 25% of entrants in addition to the 20-30% referred or selected for review. The introduction of guidelines increased the overall proportion of children discussed with teachers and reduced, in part, the proportion scheduled for review. This study informs the debate about selective entry medicals. The findings will be of interest to commissioners of health care who have the responsibility for contracting for school entry assessments.