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Get DE 37-06-10-01-01-01

Family Child Care Large Family Child Care Home Day Care Center CHILD HEALTH APPRAISAL BIRTHDATE SECTION A: TO BE COMPLETED BY PARENT BEFORE PHYSICAL EXAMINATION CHECK IF CHILD HAS PROBLEMS WITH ANY OF THE FOLLOWING: GIVE ADDITIONAL COMMENTS BELOW Allergies Frequent Colds Fainting Physical Handicap (food, medicine, bee sting etc.) Hearing Difficulty Speech Difficulty Behavior Problem Constipation/Diarrhea Seizures Vision Diff.

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