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Tational Age (GA) Current Weight 1 PATIENT INFORMATION Birth Weight Date Recorded kg (lb) kg (lb) Street Address City County State ZIP Code M F Date of Birth Subscriber ID Number Sex 33 34 weeks GA (765.27) 35 36 weeks GA (765.28) 27 28 weeks GA (765.24) Middle Initial 31 32 weeks GA (765.26) 24 weeks GA (765.21 765.22) 25 26 weeks GA (765.23) First Name 29 30 weeks GA (765.25) Chronic Respiratory Disease Arising in the Perinatal Period.

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