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All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

 

  (Last, First, M.I.): Baby K X M F

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 !" 
 Dr. Jon Jantz
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$   Measles Mumps Rubella Chickenpox Rheumatic Fever Polio X Non-Applicable

 % cepatitis B IPV

 X @ Birth X @  Months
X @  Months @ 4 Months
@ Months
DTaP PVC
X @  Months X @  Months
@ 4 Months @ 4 Months
@ Months @ Months
cib Rota
X @  Months X @  Months
@ 4 Months @ 4 Months
@ Months @ Months
! &    
Born with immature lungs and experienced breathing problems within seconds of being born. ce was hospitalized in the special care nursery for 4
days before lungs were mature and functioning normal.