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Ess Phone Check the following conditions and diseases the child has had: Conditions: Allergies Heart Asthma Hernia Diabetes Kidney Epilepsy Orthopedic Diseases: Chicken Pox Rheumatic Fever Scarlet Fever Has this child ever been hospitalized Why? MEDICAL EXAMINATION BY HEALTH CARE PROVIDER Height: Weight: Vision: OD 20/ OS 20/ OU 20/.

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