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0 o 1f21765 - 2004 Medical Arts Press 1-800 328-2179 City/State Minor/Child s Physician Date of last physical examinalion Receiving any medication or drugs. Vers. D2SSS04 YES For what service Date of last visit to a dentist Has child complained about dental problems No. O A. I. D. S.lH. I. V. D D Anemia D Asthma D Bladder Problems D Cancer Diabetes Drug/Alcohol Abuse D Hepatitis Cerebral Palsy Chicken Pox Convulsions Epilepsy Fainting Hearing Problems D Rheumatic Fever D Sinus Problems D...
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