6-11 Year Well Child Exam Form

6-11 Year Well Child Exam Form - 6 11 Year Well Child Exam...

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6 - 11 Year Well Child Exam Age _________ DOB _________ (use growth charts for below) Height _________in/cm _________%  Weight _________lbs/kg _________%  BMI _________  B.P. _________/_________  Allergies:                                                                     Medications: Interval History: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________ Home (chores, TV, videogames) Do you have chores to do at home? How much do you watch TV, play videogames and on the computer time? Education (school progress, teacher concerns)
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6-11 Year Well Child Exam Form - 6 11 Year Well Child Exam...

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