Please list all those living in the child's home.
Please list other siblings not living in the home.
During pregnancy, did the mother:
Mother lab results:
After birth, did the baby get:
Has your child ever had any of the following problems? DK = Don't Know
Add Surgical Procedure
Have any of your child's parents, grandparents, aunts, uncles, brothers, or sisters ever had any of the following conditions? DK = Don't Know
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