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Please fill out this form to the best of your ability. If you have any questions, please call us at 910-673-5437.
Please tell us all other doctors or specialists involved in your child's
Please list all medical diagnoses your child has
Please list all medications your child takes:
Please list any tests, surgeries, and/or
hospitalizations since birth (MRI, EEG):
Please write the age when your child first performed the following skills
(choose months or years):
Does your child use any of the following at home or at school?