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Get and Sign New Patient Form NorthShore University HealthSystem Northshore

Get and Sign New Patient Form NorthShore University HealthSystem Northshore

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Pale skin spots or birthmarks Yes No Headaches seizures or loss of consciousness Broken bones or head injuries Vision Hearing loss or ear infections Sense of smell Eating swallowing appetite Heart or blood pressure Asthma Yes Medication and Allergies What medicines vitamins or supplements does your child take Drug Allergies What Happened in the allergic reaction Hospitalization Was your child hospitalized overnight Yes Which year No if yes please fill out the boxes below. Where Why...
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