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Was this child premature? Yes No If yes, how many weeks? Were there problems with this child s delivery? Yes If yes, list: No Did this child have any unusual problems in the hospital such as trouble breathing, blue spells, yellow jaundice, trouble feeding, etc.? If yes, please list: Did this child need special treatment while in the hospital such as oxygen, transfusions, lights? Was (is) this child breast fed? No Yes Did (does) this child have any problems with breast feeding.

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