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Get Fitness Assessment Form

______ Weight________ Date of Birth____________ Gender___________ CHECK IF CHILD HAS OR HAS HAD ANY OF THE FOLLOWING ____ Rheumatic Fever ____ Skin Condition ____ Chronic Cough ____ Tuberculosis ____ Poor Vision ____ Wears Glasses ____ Hearing Loss ____ Frequent Nose Bleeds ____ Frequent Nose Infections ____ Frequent Throat Infections ____ Shortness of Breath ____ Heart Murmur ____ Heart Disease ____ Broken Limbs ____ Back Deformity ____ Stomach Pain ____ Kidney Trouble ____ Frequent Constip.

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