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Child Medical Record Form

Is your child currently under the supervision of a physician? *
Does your child have any history of vision impairment? *
Does your child wear corrective lenses?*
Does your child have a hearing impairment? *
Does your child wear a hearing- aid? *
Does your child have a speech impediment?*
Has your child ever been tested for intellectual disability or developmental delay?*
Does your child have an IEP? *
Does your child have an existing illness?*
Does your child currently take medication?*
Does your child have allergies? *
Has your child been diagnosed with an emotional disorder? *
Has your child been diagnosed with a behavioral disorder?*
Is your child participating in a behavioral intervention plan?*
Is your child participating in a reinforcement plan? *
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