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Medical history

* indicates a required field

Please indicate if your child has a history or diagnosis of the following conditions:
Complications during pregnancy or delivery (including but not limited to prematurity) *(required)
Developmental delay or failure to thrive *(required)
Sinusitis, sleep apnea, or snoring *(required)
Congenital heart defect/disease or heart murmur *(required)
Asthma, reactive airway disease, cystic fibrosis or breathing problems *(required)
Jaundice, hepatitis, or liver problems *(required)
Gastroesophageal reflux disease (GERD), stomach ulcers, or intestinal problems *(required)
Lactose intolerance, food allergies, dietary restrictions, or eating disorder *(required)
Bladder or kidney problems *(required)
Scoliosis, limited us arms/legs, muscle/joint/bone problems *(required)
Rash/hives, eczema, or skin conditions *(required)
Impaired hearing, vision, or speech *(required)
Cerebral palsy, brain injury, epilepsy or seizures *(required)
Intellectual disability or learning delays *(required)
Attention Deficit/Hyperactivity Disorder (ADD/ADHD) *(required)
Behavioral, emotional, communication, or psychiatric problems/treatment *(required)
Abuse history (physical, emotional, sexual, or psychological) *(required)
Diabetes, hyperglycemia or hypoglycemia *(required)
Anemia, sickle cell disease/trait, or blood disorder *(required)
Hemophilia, easy bruising, or excessive bleeding *(required)
Cancer, tumor, chemotherapy, or radiation history *(required)
Bone marrow or organ transplant *(required)
Mononucleosis, tuberculosis, scarlet fever *(required)
MRSA, sexually transmitted disease, HIV/AIDS *(required)
Any other medical condition or diagnosis not listed above? *(required)