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3Child Medical HistoryDate: Patient: LASTFIRSTBirthdate: / / Middleton your child: (Please circle one) YESNOHave a current physician? Physical: Xenophon # Take ANY prescription / nonprescription medication(s)
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Does my child have any food allergies or dietary restrictions that we should be aware of?
The child's parent or guardian is responsible for filling out the form.
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Information about the child's medical history, allergies, and dietary restrictions must be reported.
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