WCC Other: SOCIAL AND FAMILY HISTORY Name: Age: Health: Occupation: Grade Completed: Mother: G P TA SA L Father: Parent s Plans: Name: Sex: DOB: Health: Grade n School i Siblings: Med Allergies: No Yes What Med? Reaction: Other Allergies: Hosp/Surgeries: Current Medications: Immunization Status: UTD Reac Date of most recent PPD: tion to past immunizations: BIRTH HISTORY Where was child born? Length of pr eg: wks Preg Complications: Use of Dru.
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