Epstein Secrets

10) F 1 (11)RACFJETHMC ORIGIN y • Native 0 B-Black, Non-Hispanic 0 H-Hispanic 0 W-White, Non-Hispan

ALTH HISTORY (Serious Illnesses Inures explain) (attach narrative it additonal space needed) C. I ARARATARY Ina inelinlaelli e Tuberculin test Sickle Cell type date result NAME: TITLE: ADDRESS: (Please Print) r-rdl- OH 3040. 10116 (lieplooli 14R5-14 Form 3040 which easy be used) Mock Plumbot. 5

Not Hispanic O American Indian/Native Alaskan O Black, Not Hispanic O Asian/Pacific Islander STUDENT

n) (attach narrative d additional space needed) C. LABORATORY (as indicated) t- rnoglcbin/Hemafocrit Stool (O & Tuberculin test: LP 1C1 Sickle Cell d NAME: TITLE: ADDRESS: (Please Print) 1 7A /7 5 OH 3040. 10/16 (Rapacas HRS-ef Form 3040 when may 0* oseie) (Stock Nwnbsr 57444430 JU0 2)

SEX: RACIAL/ETHNIC GROUP: G Mao Not Hispanic G Black Not Hispania -c Dale First Entered This ()kirk'

Illnesses Injuries: explain) (attach narrative it additional space needed) C. LABORATORY Hemoglobin/Hematocrit Stool 1O & P) Tuberculin test: Sickle Cell Lead Authorized Signature OH 3040. 10190 (Replaces NRS-li Form 3040 which may be used) (Slack Number 5741-000-3040-2) EFTA01710221 ERs Studen