Well Child Exam Early Childhood: 4 Years - Michigan
Next Well Check: 5 years of age Developmental Surveillance on page 2. Page 3 required for Foster Care Children Medical Provider Signature: PAGE 2 – WELL CHILD EXAM – EARLY CHILDHOOD: 4 Years Developmental Surveillance (This page may be used if not utilizing a Validated Developmental Screener) Date Child’s Name DOB ................
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