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Child's Name (First Name, Last Name)
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Name of guardian completing
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Todays Date (mm/dd/yyyy)
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What problems originally brought you to see us for your child?
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Health gains your child has experienced:
• • •
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We would love to hear your opinions or comments regarding your experience at our office: (If nothing, you can write n/a)
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We will review any scans or examinations with you, at the appointment following your child's progress exam. It may be necessary to reschedule your appointment, so please see the front desk on your way out!
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