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New Kent County Public Schools Medical Information - Clinic Record Student s Name Date of Birth Mailing Address Street City Sate Zip Home Telephone Grade Medical History Allergies seasonal Hypertension high blood pressure Allergies Food Psychiatric Disorder Allergic Reaction Bee Sting Severe ADD/ADHD Cardiac Problems Asthma Hearing Impairment Diabetes Seizure Disorder Ear Infections Other Medication taken daily Reason for medication Special medical instructions Please list any health concerns...
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