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Get Autism Advocacy Intake Form

Advocates for Families Autism Intake Form Patient Name Child s age Child s date of birth Hometown Travel time to clinic How did you hear about our clinic Diagnosis Age at diagnosis Previous Biomedical Care include diets supplements labs medications Main Concerns about your child Family Father s occupation Significant medical history Mother Father Siblings Relatives with neurodevelopmental issues Prenatal History Maternal age Did the mother have .

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