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Does your child take any medications?
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[esigcf7 formid="234216" field_id="medications" ]
|
[esigcf7 formid="234216" field_id="medication-note" ]
|
|
Does anyone smoke in your child’s home?
|
[esigcf7 formid="234216" field_id="smoke" ]
|
|
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Allergies
|
[esigcf7 formid="234216" field_id="allergies" ]
|
[esigcf7 formid="234216" field_id="allergies-note" ]
|
|
Recent cold, cough or reactive airway
|
[esigcf7 formid="234216" field_id="coldcough" ]
|
[esigcf7 formid="234216" field_id="coldcough-note" ]
|
|
Snoring, asthma or breathing problems
|
[esigcf7 formid="234216" field_id="snoring" ]
|
[esigcf7 formid="234216" field_id="snoring-note" ]
[esigcf7 formid="234216" field_id="snoring-note-2" ]
|
|
Heart trouble, murmur, or heart surgery
|
[esigcf7 formid="234216" field_id="heartmurmur" ]
|
[esigcf7 formid="234216" field_id="heartmurmur-note" ]
[esigcf7 formid="234216" field_id="heartmurmur-note-2" ]
|
|
Surgery or hospitalizations
|
[esigcf7 formid="234216" field_id="surgery" ]
|
[esigcf7 formid="234216" field_id="surgery-note" ]
|
|
Problems or complications with anesthesia
|
[esigcf7 formid="234216" field_id="complications" ]
|
[esigcf7 formid="234216" field_id="complications-note" ]
|
|
Cerebral palsy, Epilepsy, Seizures or Fainting
|
[esigcf7 formid="234216" field_id="palsy" ]
|
[esigcf7 formid="234216" field_id="palsy-note" ]
|
|
Developmental delay, Autism or ADHD
|
[esigcf7 formid="234216" field_id="autism" ]
|
[esigcf7 formid="234216" field_id="autism-note" ]
|
|
Any other medical conditions?
|
[esigcf7 formid="234216" field_id="medicalconditions" ]
|
[esigcf7 formid="234216" field_id="medicalconditions-note" ]
|
|
How many minutes is your drive from home to the dental office?
|
[esigcf7 formid="234216" field_id="labdistance" ]
|
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