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Please check if your child has a history of any of the following Asthma Chicken Pox Congenital Heart Failure Coxsackie viruses Diabetes Fifth s Disease Fracture Frequent Ear Infections Lyme Disease Pneumonia/Bronchitis Seizure Others Details I understand that all reports and testing results provided to Primrose School will be treated confidentially. Hearing 3. Medical Screenings Yes No Date b If yes what were the results and recommendations if any 4. Allergies a Does your child have any...
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