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ION Screen Date (MMDDYY) Indicate the EPSDT periodic screening age being reported Sex 14 d 30 d 2 m 4 m 6 m 9 m 12 m 15 m 18 m 2 y 3 y 4 y 5 y 6 y 8 y 10 y 12 y 14 y 16 y 18 y 20 y ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š ï‚š Name (Last, First, Middle Initial) Medicaid/QUEST ID 0 MEASUREMENTS Blood Pressure M F ï‚š ï‚š Birthdate (MMDDYY) 0 For infants, head circumference and weight for length should be as.

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