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Get VA Newcomer Health Program Supplemental Data Collection Form 2013

Unter #:_________________________________ Health District: _____________________________ Did the patient receive an initial health screening? Yes No DATE OF INITIAL ASSESSMENT:_____/______/________ If the patient did not receive a screening, why not? Moved Refused Never located Missed multiple appts.  Unknown Other_____________________________ Assessment Findings: Is the patient: Male Female Was the dental evaluation WNL? Was the hearing evaluation WNL? Was t.

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