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NNUAL H EALTH ASSESSMENT S TUDENT I NFORMATION Class of: Student Name (First, Middle Initial , Last): Telephone Number: HOME Age: Email: Sex: CELL MALE FEMALE H EALTH ASSESSMENT P LEASE ANSWER THE F OLLOWING Q UESTIONS : 1. Have you experienced any of the following in the past year? Blood or body fluid exposure No Yes If yes, did you report this? Please comment on any follow-up or post-exposure prophylaxis: Rash No Yes Jaundice No Yes Back Pain No Yes Night Sweats No Yes.

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