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Parent 1 Relationship
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Parent 2 Relationship
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Convulsion/Epilepsy
Abnormal Bleeding
Hearing Impairment
Handicaps/Disabilities
Developmentally Delayed
Nail Biting
Grinding Teeth
Rheumatic Fever
HIV Positive or AIDS
Hemophilia
Asthma
Hepatitis
Tuberculosis
Chronic Upper/Respiratory Problems
Is your child currently under the care of a physician?
Vision Problems
Any operations (Explain Below)
Describe your childs current physical health?
Any Hospital Stays (Please explain below)
Kidney/Liver Problems
Allergies
Peanut Allergy
Pregnant
Smoker
ADD & ADHD
Autism
Downs Syndrome
Speech Problems
Thumb Sucking
Lip Sucking
Nursing / Bottle / Sippy Cup
Mouth Breathing
Does your child have a heart condition?
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Cancer
Diabetes
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