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Indiana University South Bend HEALTH & WELLNESS Health History Please print the following Information clearly: Name Date of Birth Age Address City State Zip Student ID # IU Email Phone Male Female

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1. Visit the Indiana University South Bend website.
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Indiana University South Bend is a regional campus of Indiana University located in South Bend, Indiana.

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All students, faculty, and staff affiliated with Indiana University South Bend are required to file appropriate forms and reports.

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