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Sure Corrective Lenses Yes Immunization Dates: Measles or MR Pulse No Sport Temp Corrected Vision R20/ L20/ TD or Tetanus Physical Exam (Please elaborate on any abnormality in the history) Normal Abnormal Head, Face and Scalp Mouth, Nose & Throat Tonsils in ( ) out ( ) Ears Eyes Neck (thyroid) Lymph nodes Lungs and Chest Breasts Heart Vascular system Abdomen (include hernias) Genitalia Musculoskeletal (strength and range of motion) Neck Shoulders Elbows Hands/Wrists Spine Knees Ankles Fee.

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