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Long Term Follow-up Data Collection
Data form:
Is Jennifer still in your care? [_]YES [_] NO
If NO, please provide any contact information you may have
Street address
City, state, zip
Phone
Data last seen (mm/dd/yy):
Development: Normal Concerning
Gross motor
Fine motor
Personal-Social
Language
Growth:
Height inches centimeters
Weight pounds kilograms
Has Jennifer been hospitalized in the last year? YES NO
If yes, how many times?
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5600 Fishers Lane Rockville, MD 20857