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  Parent t/Guardian:             D.O.B.: _ _____/_____/_ _____    Age: _      ___ Months       Prema ature?  Yes ___ _  No ___  If ye es:  how many weeks     Gende □ Male   □ Female   Ethnic Origin:   □ Hispanic  □ C er:   Caucasian  □ A African Americ □ Native A can   American  □ A Asian   □ Other    Reaso on for Visit:  □ Req quested Infant ® Assessme tSEE ent  □ Refferred; rep.

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