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Headaches:
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Comments:
|
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Anxiety:
|
Comments:
|
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Nausea:
|
Comments:
|
|
Drowsiness:
|
Comments:
|
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Irritability:
|
Comments:
|
|
Difficulty falling asleep:
|
Comments:
|
|
Difficulty staying asleep:
|
Comments:
|
|
Abdominal Pain
|
Comments:
|
|
Decreased Appetite:
|
Comments:
|
|
Increased Appetite:
|
Comments:
|
|
Tics-involuntary movement:
|
Comments:
|
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Depression:
|
Comments:
|
|
Thoughts of hurting self or others?
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Comments:
|
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Other:
|
|
|
School Hx
|
Current Grade/Retained Grade
/
|
|
Retained
|
Comments:
|
|
IEP/504 Plan:
• • •
|
Comments:
|
|
Suspended/ISS/Expelled:
|
Comments:
|
|
Medical Hx
|
|
|
Tobacco Use:
|
Comments:
|
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Drug Use:
|
Comments:
|
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Alcohol Use:
|
Comments:
|
|
Sexual Hx:
|
Comments:
|
