Preventive Care Forms - Anthem

Exposure to tobacco smoke: Yes/ No TB Risk: Yes / No . Hep B Risk: Yes / No. GROWTH DEVELOPMENT: [ ]Hops on one foot [ ]Plays with several children [ ]Counts four pennies [ ]Recognizes 3 to 4 colors [ ]Copies a square [ ]Knows opposites [ ]Catches, throws a ball [ ]Knows name, address, phone no. PARENTAL/PATIENT CONCERNS: ................
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