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Ballyhara, Two-mile water, Wicklow, Co. Wicklow
087 600 2599
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Benefits to Autism
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Booking
Participant’s Application and Health History
General Information
Participant Name
D.O.B
Age
Height
Weight
Gender
Address
Mobile no
Home Phone
E-mail
Parent/ Guardian/Caregiver
Address
Mobile
Home Phone
Diagnosis
Date of Onset
Please indicate current special needs in the following areas:
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Circulation
Emotional/Mental Health
Behavioral
Pain
Bone & Joint
Muscular
Thinking / Cognition
Allergies
Comments
Medications
Physical Function
Social Function
Goals
Signature
Tick to conform
Date
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