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DOCTOR:  SIX YEAR OLD VISIT

                                                          DATE:

WEIGHT:  lbs.                Blood Lead risk assessment
HEIGHT:  Ins.                Tuberculosis risk assessment

                                         Visual Acuity

INFORMATION FOR THE DOCTOR:

QUESTIONS/PROBLEMS:

NOTES:

Safety Tips: Please read the following sections In this booklet.
            Section Vlll-K. Water Safety
            Section Vlll-I. Fire Safety

Your next appointment for a physical is when your child is 7 years old and then
annually after that.

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