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PROGRAM CHILD IS ENROLLED IN Head Start - State Preschool Head Start Center Base Early Head Start Home Base FCC Confidential Medical Record Part II Physical Exam and Screening Tests LAST NAME FIRST NAME MIDDLE INITIAL OF CHILD SEX DATE OF BIRTH M NAME OF PARENT OR GUARDIAN F DELEGATE AGENCY NAME/SITE TO BE COMPLETED BY HEALTH CARE PROVIDER PHYSICAL EXAMINATION ADMINISTERED BY TYPE OR PRINT NAME TYPE OF PRACTICE SIGNATURE TELEPHONE NUMBER DATE OF EXAM ADDRESS EXAMINATION RESULTS HEIGHT inches...
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