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Get Ma School Health Record Health Care Provider’s Examination 2005

_____________________________________________________________________ _______________________________________________________________________________________________________ Pertinent Family History Current Health Issues Y N Allergies: Please list: Medications ______________________ Food _________________ Other ______________ History of Anaphylaxis to ___________________ Epi-Pen: Yes No Asthma: Asthma Action Plan Yes No (Please attach) Diabetes: Type I Type II Seizure disorder: ______________.

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