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Slide Presentation from the AHRQ 2007 Annual Conference

Long Term Follow-up Data Collection

Text Description is below the image.

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?