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Get IL IL444-4737 2002

Plate Other Other Concerns? Eye/Vision Problems? Glasses Other Concerns? Contacts Information on this form may be shared with appropriate personnel for health and educational purposes. Last Exam ____________ Parent/Guardian Signature TO BE COMPLETED BY MD/APN/PA Date (* INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES OR SELECTED SCHOOLS AND PROGRAMS) Date Results Date Results Hemoglobin * or Urinalysis Hematocrit * Sickle Cell * (as needed) Lead Questionnaire* Comp.

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