{"text":"Lothian Regional Council Child\u2019s Surname \nDepartment of Social Work ( @ \nForename(s) \n{ i ( \n! ! \\ \nMedical Information at Application (RIC 2) BB CP.No. \nPrevious Infections - indicate YES or NO or NOT KNOWN. If YES, give date. \nMeasles \\ . : Chicken=pox \nGerman Measles | Scarlet Fever | \nWhooping Cough |~ Diphtheria \nMumps N Other = Specify \nDysentery \nCompleted Inoculations - indicate YES or No. If Yes, give date. \nSmallpox e Gl Polio \nTriple Antigen-diphtheria, - | 19 7 Measles ) [Tt \nwhooping cough, tetanus. { \nB.C.G. ( el Other = Specify (eg. German Measles) \nHas the chiid had any operations? If so, where, when, and for what? ; \u2019 } \n{ ~1 < | 0 ] ) \nN - | S | \/ \nAL G f A~ : g . A ! \nS ( - ) \n\/ \\( CP ATICOA \nIs a special diet required e.g. diabetic? If so please specify. \nHas the child attended a Child Guidance Clinic? If so when and where? \nDoes the child have any particular behavioural difficulties? \nN s : M oo { A 1 T T o . NG ! \/ \nPARENT\u2019S DECLARATION \n| declare that the information given on this form is correct. \nSignature Date \nPLEASE COLLECT NATIONAL HEALTH CARD 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