*MEDDAC Pam 25-2 DEPARTMENT OF THE ARMY U.S.

ARMY MEDICAL DEPARTMENT ACTIVITY Fort Huachuca, Arizona 85613-7040 MEDDAC Pamphlet No. 25-2 Military Publications INDEX OF MEDDAC BLANK FORMS PARA PURPOSE-------------------------------------------1 SCOPE---------------------------------------------2 REFERENCE-----------------------------------------3 REQUISITIONING MEDDAC FORMS, WS, HO, OP, FL-------4 CREATION OF NEW MEDDAC FORMS, WS, HO, OP, FL------5 APPENDIX A - INDEX OF MEDDAC FORMS, WORKSHEETS HANDOUTS, OVERPRINTS AND FORM LETTERS----------1. HISTORY: publication. This issue publishes a revision of this PAGE 1 1 1 1 1 A-1 24 October 2003

2. PURPOSE. This pamphlet provides a current index of R. W. Bliss Army Health Center Forms, Form Letter (FL), Overprint(OP), Handout(HO), and Worksheet(WS); instructions for the proper preparation of forms used in requesting creation of new or revised forms. 3. SCOPE. This pamphlet applies to USA MEDDAC, Ft Huachuca.

4. REFERENCE. AR 25-30, 28 February 1989, The Army Integrated Publishing and Printing Program. 5. REQUISITIONING MEDDAC FORMS, FL, OP, HO, AND WS. Items will be requisitioned on a DD 844 (Request for Printing and Bindings). A copy of the item to be printed will be attached, with a paper clip to the DD 844. Send to USA MEDDAC, Information Management Division (IMD), ATTN: MCXJ-IM-PW (Publications). Allow five working days for completion. 6. CREATION OF NEW FORMS, FL, HO, AND WS. For creation of new or revised MEDDAC Forms, Form letters, Handouts, and Worksheets the proponent will prepare a DD Form 67 (Request for Approval of Form), attach a copy of the proposed item and send directly to IMD, ATTN: MCXJ-IM-PW.

_______________ *This pamphlet supersedes MEDDAC Pam 25-31, 1 December

MEDDAC Pam 25-2

24 October 2003

For creation of new or revised RWBACH Overprints proponent will prepare DD Form 67 and attach a copy of the proposed overprint. Overprint requests will be routed thru Patient Administration. The proponent of this publication is Information Management Division. Send comments and suggested improvements on DA Form 2028 to CDR, USA MEDDAC, ATTN: MCXJ-IM, Fort Huachuca, AZ 85613-7040 FOR THE COMMANDER:

OFFICIAL:

MICHAEL L. KIEFER LTC, MS Deputy Commander for Administration

ROBERT D. LAKE Information Management Division DISTRIBUTION: A

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MEDDAC Pam 25-2

APPENDIX A INDEX OF RWBAHC FORMS, OVERPRINTS, FORM LETTERS, WORKSHEETS AND HANDOUTS
RWBAHC FORMS RWBAHC FORM # 3 6 29 50 79 95 109 155 185 194 209 269 281 286 286-A METS 288 295 296 297 TITLE Medical Care Support Equipment Patient Menstrual Record Prescription For OTC MED Transfusion Reaction Investigation Pharmacy Manufactures Batch Log Authority for Release of Blood Viral Hepatitis Case Report Transfusion Committee Report Sobriety Exam and Blood Alcohol Determination Patient Concern Form Report of Impoundment/Cage Card Multiple Prescription Pharmacy-Patient Medication Profile RWBAHC, Mass Casualty Card RWBAHC, Mass Casualty ID Badge and Instructions Special Power of Attorney Microwave Oven Survey Report of Microwave Oven Survey USA MEDDAC Inprocessing Checklist DATE 1 Nov 1990 1 Nov 1989 1 Jan 1999 1 Mar 1985 1 Mar 1985 10 Feb 1981 1 Jul 1990 24 Oct 1979 1 Jul 94 1 Mar 1991 24 Jan 1979 1 Jul 1988 1 Jan 1995 1 Jan 1983 PROPONENT MCXJ-LO MCXJ-DS MCXJ-RX MCXJ-DP MCXJ-RX MCXJ-DP MCXJ-PM MCXJ-DP MCXJ-DP MCXJ-CSD MCVS-SWR-H MCXJ-RX MCXJ-RX MCXJ-METS MCXJ-

1 Aug 1983 1 Apr 1983 1 Apr 1985 1 Sep 1983 1 Feb 1988 MCXJ-P

MCXJ-PM MCXJ-PM MCXJ-PD

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RWBAHC FORMS RWBAHC FORM # 305 310 313 314 315 316 320 338 356 358 363 367 368 377 387 399 408 411 414 415 TITLE Code Blue Critique Form Breast Questionnaire Dept of Radiology Appt Log Special Procedures Dept of Radiology Appt Log Ultrasounds Authorization for Disclosure of Information Sanitary Inspection Report Spouse/Child Abuse/Neglect Limits on Confidentiality of Mental Health Information Evaluation of Education Program Supplemental Care In-house Checklist Community Mental Health History Questionnaire QA Problem List Certificate of Training Concurrent Review Inpatient Records Unlocatable Record Checklist Recovery Room Report Immunization Clinic Log-In Sheet Fire Drill After Action Monitoring and Evaluation Report Hematology Worksheet DATE 1 Feb 1985 1 Sep 1995 1 Sep 1987 1 Jan 1988 1 Oct 1985 1 Nov 1985 1 Jun 1986 1 Mar 1987 1 Aug 1987 14 Aug 1987 1 Sep 1987 1 Oct 1987 1 Oct 1987 1 Jan 1988 1 Jun 1991 1 Jul 1988 1 Jul 1994 1 Jul 2001 1 Dec 1989 1 Dec 1989 PROPONENT MCXJ-CSD MCXJ-DR MCXJ-DR MCXJ-DR MCXJ-PA MCXJ-PM MCXJ-MH MCXJ-MH MCXJ-METS MCXJ-PA MCXJ-MH MCXJ-PI MCXJ-PM MCXJ-PA MCXJ-PA MCXJ-DN MCXJ-CM MCXJ-SAF MCXJ-PI MCXJ-DP

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RWBAHC FORMS RWBAHC FORM # 416 421 430 432 433 435 440 443 444 450 451 461 474 475 476 479 480 481 482 TITLE Customer Complaint Form Special Drug Request Surgical/Invasive Procedure Report Special Event/Sentinel Indicator Review Post Anesthesia Patient Questionnaire Now Privileged HCP Annual Evaluation/Creditable Review Packed Cells Transfusion Record The We Care People Award Nomination Whole Blood Transfusion Record Automated Information System Accreditation Antineoplastic Therapy Patient Profile CHCS Data Pharmacy Service Non-formulary Medication Order Form Outpatient Medical Record Review Pharmacy Service Unit Inspection Checklist DOR Mammo/VCOG/HSG Appointment DOR Special Appt DOR File Control Pharmacy Sterile Products Order Card DATE 1 Jan 1990 1 Oct 1991 1 Jun 1997 1 Aug 19991 1 Aug 1991 1 Dec 1991 1 Oct 1992 1 May 1996 1 Mar 1993 1 Mar 2001 1 Feb 1994 1 Oct 1995 1 Oct 1994 1 Oct 1994 1 Nov 1994 1 Sep 1995 1 Sep 1995 1 Sep 1995 1 Nov 1995 PROPONENT MCXJ-CSD MCXJ-RX MCXJ-DS MCXJ-DS MCXJ-DS MCXJ-PI MCXJ-DP MCXJ-CSD MCXJ-DP MCXJ-IM MCXJ-RX MCXJ-IM MCXJ-RX MCXJ-PA MCXJ-RX MCXJ-DR MCXJ-DR MCXJ-DR MCXJ-RX

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RWBAHC FORMS RWBAHC FORM # 484 485 491 492 493 495 497 498 499 500 501 502 503 504 505 506 507 TITLE HIV Screening Purchase Request Commander Request for Mental Health Evaluation Third Party Collection Program Claims Action Log Coagulation Quality Control Automated Information Systems Access Request Celebrex Prescription Prilosec Prescription Insurance Verification Form TB Skin Test Index Card Immunization Index Card Recruitment/Relocation Bonus Service Agreement Retention Bonus Service Agreement Monthly Fire Inspection Monthly Safety Inspection RWBAHC Pharmacy Service Prescription Info Request Certification of Hard Drive Disposition DATE 1 Sep 1996 1 Aug 1996 1 May 1997 1 Jul 1997 1 Sep 1997 1 Mar 1999 1 Jun 1999 1 Jun 1999 1 Jun 1999 1 Dec 1999 1 Dec 1999 1 May 2001 1 May 2001 1 Jul 2001 1 Jun 2003 1 Jan 2002 1 Oct 2003 PROPONENT MCXJ-DP MCXJ-LO MCXJ-MH MCXJ-RM MCXJ-DP MCXJ-IM MCXJ-RX MCXJ-RX MCXJ-PA MCXJ-PEDS MCXJ-PEDS MCXJ-RM MCXJ-RM MCXJ-SAF MCXJ-SAF MCXJ-RX MCXJ-IM

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RWBAHC FORMS RWBAHC FORM # 508 509 510 511 513 514 515 516 517 518 519T 520T 521 522 523 TITLE RWBAHC Unit Specific Orientation RWBAHC Competencies DATE 1 May 2002 1 May 2002 1 May 2002 1 May 2002 1 Jan 2003 1 Apr 2003 1 Jan 2003 1 Jan 2003 1 Apr 2003 1 Apr 2003 1 Aug 2003 1 Aug 2003 1 Aug 2003 1 Aug 2003 1 Sep 2003 PROPONENT MCXJ-METS MCXJ-METS MCXJ-METS MCXJ-METS MCXJ-RX MCXJ-QM MCXJ-QM MCXJ-QM MCXJ-FCC MCXJ-MH MCXJ-IM MCXJ-IM MCXJ-PI MCXJ-PI MCXJ-DS

RWBAHC Pain Management Competencies RWBAHC Age Specific Competencies Pharmacy Manufacturing Batch Log Department Meeting Min/Action Log Functional Area Assessment Functional Area Doctors Release Commanding Officer Request For ER Mental Health Eval Request to Restrict Medical or Dental Information Authorization for Disclosure of Medical or Dental Info Outpatient Medical Record Peer Review Risk Management Peer Review Temperature Record Chart

RWBAHC OVERPRINTS RWBAHC OP # SF559 OP 9 TITLE Allergen Extract Blood Pressure Screening Program DATE 1 Jul 187 1 Nov 1987 PROPONENT MCXJ-DM MCXJ-PM

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RWBAHC OVERPRINTS RWBAHC TITLE OVERPRINT # OP 37 OP 68 OP 69 OP 70 OP 74 OP 75 OP 76 OP 77 OP 79 OP 81 OP 87 OP 91 OP 92 DS OP 93 OP 94 OP 95 OP 99 OP 101 OP 103 Post Anesthesia Nursing Notes Post Anesthesia Well Baby Visit OCH Physicals Same Day Surgery Assessment SDS Preadmission Assessment SDS Discharge Instructions SDS Preoperative Instructions Record of OPT Exam Allergy History Ambulatory Surgery Recovery Flow Sheet PT Discharge Note Instructional Class on Causes DX, RX, Rhab of PFPS Patient Attended Back Class for Instructions in How to Care for LBP Assistive Ambulation Device Instruction Patient Attended Prenatal Exercise Class Respirator Certification Consent for Intravenous Admin of Iodinated Contrast Initial Interview - Community Mental Health SVC

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DATE 1 Jul 1990 1 Jul 1990 1 Sep 1990 1 Sep 90 1 Jan 1994 1 Jul 1993 1 Jan 1994 1 Jan 1995 1 Nov 1990 1 Nov 1990 1 Mar 1991 1 Mar 1991

PROPONENT MCXJ-DN MCXJ-DS MCXJ-PEDS MCXJ-PM MCXJ-DN MCXJ-DN MCXJ-DN MCXJ-DN MCXJ-DS MCXJ-DM MCXJ-DS MCXJ-DS MCXJ-

1 Mar 1991

1 Mar 1991 1 Mar 1991 1 Mar 1991 1 May 1991 1 May 1991 1 Jun 1991

MCXJ-DS MCXJ-DS MCXJ-DS MCXJ-PM MCXJ-DR MCXJ-MH

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RWBAHC OVERPRINTS RWBAHC TITLE OVERPRINT # OP 107 OP 113 OP 114 OP 115 OP 116 OP 124 OP 127 OP 128 OP 129 OP 130 OP 131 OP 132 OP 133 OP 136 OP 137 OP 138 OP 139 OP 144 OP 147 OP 155 Post Anesthesia Rec PM Flow Post-Operative Care IV Site Flow Sheet Preoperative Teaching Plan Preoperative Anesthesia Interview Preoperative Nursing Care Plan Health Maintenance Record Well Baby Clinic ACCU - Check II Glucose Monitor Home Nebulizer Air Compressor Transcultaneous Electrical Nerve Stimulation Oxygen Concentrator Initial Personal History Questionnaire Limits on Confidentiality of MH Info Closonscopy Prep Endoscopy Report Vasectomy Counseling & Agreement 3rd Party Collection Prog Insurance Info Health Risk Appraisal Industrial Hygiene Sampling Results Pain Management Flow Sheet DATE 1 Jul 94 1 Oct 91 1 Oct 91 1 Oct 91 1 Dec 91 1 Dec 91 1 Jun 02 1 Jan 02 1 Jan 92 1 Jan 92 1 Jan 92 1 Mar 92 1 Mar 92 1 May 92 1 May 92 1 Dec 95 1 May 92 1 Sep 92 1 Sep 92 1 Aug 95 PROPONENT DN DN DN DN DS DN PED AFC AFC AFC AFC MH MH DS DS DS PAD PEDS PM DN

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RWBAHC OVERPRINTS RWBAHC TITLE OVERPRINT # OP 156 OP 157 OP 160 OP 161 OP 163 OP 164 OP 165 OP 166 OP 167 OP 168 OP 169 OP 170 OP 171 OP 174 OP 175 OP 182 OP 184 OP 186 OP 187 Patient Controlled Analgesia (Non-Med) Care Plan Patient Controlled Analgesia (Med) Care Plan Gastroenteritis Angina Cellulitis Pelvic Inflammatory Disease (PID) Athroscopy Congestive Heart Failure Low Back Pain Cholecystitis Myocardial Infection Deep Vein Thrombosis Advanced Medical Directive and Organ Donation Certificate Hypertension Asthma/COPD Procedure Documentation Physical Limitations Outpatient 3rd Party Collection Program LAB Data Flowsheet DATE 1 Aug 95 1 Aug 95 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Dec 92 1 Jan 93 1 Jan 93 1 Jan 93 1 May 93 1 Apr 93 1 Jun 93 1 Jul 93 PROPONENT DN DN DN DN DN DN DN DN DN DN DN DN PAD DN DN DN DN PAD DN

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RWBAHC OVERPRINTS RWBAHC TITLE OVERPRINT # OP 188 OP 190 OP 192 OP 193 OP 194 OP 195 OP 199 OP 201 OP 202 OP 203 OP 204 OP 205 OP 209 OP 210 OP 211 OP 217 OP 218 OP 224 Pre & Post Clinic Procedure Documentation SRP's Screening Initial Personal History Well Woman Gynecolcic Exam Depo Provera Administration Record PT Ankle Eval Blood Transfusion Documentation Allergen Patch Test Standard Data Collection Transfusion of Blood and/or Blood Products Flexible Sisnoidoscopy Excision or Re-Excision for Cantaneous Malignancy Excision of skin or Subcutaneous Tissue for Diagnostic and/or Theupeutic Medical Evaluation for ADD-ADDH Follow-up Guidelines Guidelines for ADD-ADDH Medical Evaluation Allergy Injection Flow Sheet VDT Medical Surveillance Screening Personal Ear Protection Statement 5 Day Blood Pressure Check DATE 1 Jul 97 1 Apr 98 1 Jan 94 1 Jan 94 1 Jul 03 1 Feb 94 1 Mar 94 1 Mar 94 1 May 94 1 May 94 1 May 94 1 May 94 1 Sep 94 1 Sep 94 1 Sep 94 1 Oct 94 1 Oct 94 1 Jan 95 PROPONENT DN METS MH DN DN DS DN DM DS DS DS DS PEDS PEDS IMM PM PM DN

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RWBAHC OVERPRINTS RWBAHC TITLE OVERPRINT # OP 228 OP 230 OP 234 OP 235 OP 236 OP 237 OP 238 OP 240 OP 241 OP 242 OP 245T OP 248 OP 249 OP 250 OP 251 OP 252 OP 254 OP 255 OP 256 Record of Evaluation and Treatment Anticoagulation Flow Sheet Child & Adolescent Psychiatry Med Follow-up Consent to Use Medication Keloid Verruca (Wart) Audiology Referral Back Evaluation AIMS Plus EPS Community Health Nurse Case Referral Communicable Diseases Chronological Record of Medical Care/SF600 Patient Questionnaire Initial Personal History Questionnaire Initial Personal History Questionnaire Child Med History and Assessment of Acute Asthma Attaches in Adults and Children Post Procedure Phone Call Drug/Nutrient Interaction Form Treatment Plan/Master Problem List Ambulatory Surgical Procedure Unit Assessment an Care Plan DATE 1 Jul 95 1 Aug 95 1 Nov 95 1 Nov 95 1 Jan 96 1 Jan 96 1 Jan 95 1 May 96 1 Dec 96 1 May 96 1 May 01 1 Feb 98 1 Feb 98 1 Feb 98 1 Jun 98 1 May 98 1 Jun 98 1 Jun 98 1 Jun 98 PROPONENT VET PM MH MH DM DM PM PT MH PM DN MH MH MH DN DN PM MH DN

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RWBAHC OVERPRINTS RWBAHC TITLE OVERPRINT # OP 258 OP 259 OP 259A OP 260 OP 262 OP 263 OP 264 OP 265 OP 266 OP 267 OP 268 OP 269 OP 270 OP 271 OP 272 OP 273 OP 274 OP 275 OP 276 OP 277 Respiratory Therapy Treatment Flow Sheet Rabies Information and Vaccine Schedule Optometry Patient Education Active Duty Weight Counseling Supplemental Med Data Form Outpatient Encounter Med Record Nursing Discharge Ed Sheet Treatment Doc for Physical Therapy Pre-Anesthesia Eval Guideline for Crutch Ambulation Teleradiology Consent Form Hearing Test Weight to Stay Class Put Prevention into Practice - Ear Assessment Consultants Abbreviated Summary-PCM Communication Commanding Officer Request for Emergency Mental Health Evaluation Occupational Health Eye Exam Form Immunizations Asthma Action Plan for Children > 6 years Colonoscopy EGD A-11 DATE PROPONENT

1 Aug 99 1 Dec 00 1 Dec 98 1 Oct 00 1 Oct 00 1 Oct 00 1 Aug 00 1 Mar 01 1 Nov 01 1 Feb 02 1 Feb 02 1 May 02 1 May 02 1 Apr 03 1 Apr 03 1 May 03 1 May 03 1 May 03 1 Oct 03 1 Oct 03

DN PM OPT PM DN DN PT DS PM AS OHC PM PM PM MH OPT PEDS PEDS DS DS

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RWBAHC FORMLETTERS RWBAHC TITLE FORMLETTER FL 21 FL 33 FL 55 FL 94 FL 98 FL 99 FL 100 FL 101 FL 104 FL 105 FL 116A FL 123 FL 125 FL 126 FL 127 PAP Results Spectacle Pick-up Notification Eye Safety Orders Hepatitis B Follow-up Rubella & Rubella Titer Test Hepatitis B 2nd/3rd Hepatitis B Program MMPI Interpretation Referral Verification of Counseling Services Pet Vaccination Missed Appt Vet Mammogram Follow-up Care Courtesy Prescription Refill Mail-in Prescription Request RWBAHC WORKSHEET RWBAHC WORKSHEET WS 3 WS 33 WS 34 TITLE Health and Safety Inspection Checklist Hematology Quality Control Microbiology Quality Control DATE 13 Nov 79 1 Mar 84 1 Mar 84 PROPONENT PM DP DP 1 Feb 97 1 Dec 92 1 Dec 93 1 Aug 95 1 Jul 95 DATE 1 Sep 87 1 Jul 89 1 May 98 1 Jul 86 1 May 89 1 May 89 1 May 89 1 May 89 1 Aug 87 PROPONENT OB-BYN OPT PM PAD PM PM PM PM MH PAD

1 Nov 90 VET VET AFC RX RX

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RWBAHC WORKSHEET RWBAHC WORKSHEET WS 37 WS 43 WS 47 WS 51 WS 57 WS 67 WS 68 WS 73 WS 76 WS 78 WS 85 WS 86 WS 91 WS 95 WS 98 WS 100 WS 103 WS 107 WS 109 WS 110 TITLE Hematology Coagulation Emergency Crash Cart Signature Checklist Medical Records Review Outpatient Health Record Billets/Housing Inspection Immunization Checklist Quality Control For Microbiology Preventive Medicine Service STD Control Record Bone Marrow Worksheet Pharmacy MEDDAC Workload MOD Cabinet Stock List Obstetrical Ultrasound Questionnaire Pelvic Ultrasound History Evaluation Form Health Record Review Checklist Clinical Record Checklist PRC Info Sheet Data Patient Visit Chem Dailey WS Cast Room WS Patient Report Reconciliation DATE 16 Mar 81 1 Feb 97 1 May 88 1 Apr 85 1 Mar 92 1 Feb 83 1 Apr 85 1 Jul 83 1 Dec 83 1 Sep 90 1 Sep 85 1 Sep 86 1 Jun 88 1 May 91 1 May 89 1 May 89 1 Aug 89 1 Dec 89 1 Jul 90 1 Sep 90 PROPONENT DP DN PAD PM IMM DP PM DP RX RX DR DR PAD PAD DN QA LAB ORTHO DN LOG

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RWBAHC WORKSHEET RWBAHC WORKSHEET WS 111 WS 112 WS 113 WS 114 WS 115 WS 116 WS 117 WS 118 WS 119 TITLE

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DATE

PROPONENT DS IMD CSD LOG LAB RM LAB PAD PAD

QA/Risk Management Questionnaire for Anesthesia Service 1 Sep 91 Request for Assistance from IMD Utilization Management Action Tool MEDCASE Requirement folder Semen Analysis Worksheet Civilian Personnel Request for Hiring Worksheet Department of Pathology Waive Tests Patient Reports Record Release to External FAC Outpatient Record Locating Card 1 Nov 91 1 Sep 92 1 Nov 93 1 May 96 1 Aug 02 1 Aug 02 1 Sep 02 1 Sep 02

RWBAHC HANDOUT RWBAHC HANDOUT HO 111-2 HO 154 HO 153 HO 329 HO 330 HO 331 HO 333 HO 334 HO 335 TITLE Your Ultrasound Examination Your Mammography Examination Mammography Maintenance Installation and Trouble Shooting Guide Drug Food Interaction Pain Control Acetaminophen and Ibuprofen Handout Well Baby Visit Statistics Handout 15-18 Month Well Baby Visit Handout A-14 DATE 1 Jun 95 25 Jun 82 1 Apr 88 PROPONENT DR DR DR 1 Mar 01 1 Mar 01 1 Jun 01 1 Aug 01 1 Aug 01 1 Aug 01 RX DN PEDS PEDS PEDS LOG

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RWBAHC HANDOUT RWBAHC HANDOUT HO 336 HO 337 HO 338 HO 339 HO 340 HO 341 HO 342 TITLE Twelve Month Well Baby Visit Handout Six Month Well Baby Visit Handout Four Month Well Baby Visit Handout Two Month Well Baby Visit Handout 1-14 Day Well Baby Visit Handout Guides for Patients Foods Containing Iron/Foods Contain Calcium Antimicrobial Susceptibilities

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DATE 1 Aug 01 1 Aug 01 1 Aug 01 1 Aug 01 1 Aug 01 1 Apr 02 1 Aug 02

PROPONENT PEDS PEDS PEDS PEDS PEDS PEDS LAB

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