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Get IL Certificate of Child Health Examination 2015-2024

G use? Yes No Family history of sudden death before age 50? (Cause?) Yes No Yes No Dizziness or chest pain with exercise? Eye/Vision problems? _____ Glasses  Contacts  Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Yes No Bone/Joint problem/injury/scoliosis? Yes Dental  Braces  Bridge  Plate Other Information may be shared with appropriate personnel for health and educational purposes. .

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