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R: Disability ID Number: Male Sex: Female Worker Name: Phone Number: 1. Dates of Treatment First: Last: Date: Frequency: 2. Diagnosis(es): 3. Please give a history, including date(s) of diagnosis and earliest symptoms, etiology of impairment, initial findings on physical examination, treatment (including any surgical procedures) and subsequent course. 4. Please give findings on last examination. Date of last examination Height without shoes: Weight: Please give pertinent physi.
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Medical form ny Related content
Childhood Medical Disability Report
NEW YORK STATE DEPARTMENT OF HEALTH. State Disability Review Unit. Childhood Medical...
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