Please list all those living in the child’s home
During pregnancy did mother:
At what age did your child:
Have any family members had the following medical condition?
Does your child have or has he/she ever had:
Please check any symptoms your child is experiencing. If your child has more than one symptom on a line, check the relevant ones.
I hereby certify that the information given on this form is accurate and true to the best of my knowledge.
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