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  • Medical History Form

  •  -  - Pick a Date
  • Medical History

  • If your child has, or has in the past, any of the following conditions, input the age of onset:

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  • Does or did your child have any delays in the following? Please explain.

  • Your Concerns / Reason for Evaluation

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  • The information on this Medical Case History Form is true to the best of my knowledge.

  • Clear
  • Should be Empty: