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20. Summary report and conclusions of physical examination (Attach Medical Documentation) 21. Laboratory report 22. X-Ray 23. Other (specify) 24. History or physical signs of previous abuse/neglect YES NO 25. Prior hospitalization or medical examination for this child DATES 26. Physician s Signature PLACES 27. Date 28. Hospital (if applicable) Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, c.

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