Informacion del Paciente
Person to contact in case of an emergency. This should be someone other than a parent.
Please list all persons living in the same house as the child and their relationship to the child.
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Pregnancy and Birth: Please answer the following questions related to the mother’s pregnancy and child’s birth. If you answer yes, please explain.
FAMILY HISTORY: Check any illnesses that the child or members of the child’s family have had:
Due to new Healthcare Regulations, please answer the following questions.
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