Health Risk Assessment
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HIG Well Fit Solutions
Your Personal Data
First Name Middle Initial Last Name

Address

City State Zip

Daytime Phone Birth Date Company
ex: XXX-XXX-XXXX ex: XX/XX/XXXX


What is your gender?


What is your race / ethnicity? (origin)

Under the Federal Genetic Information Nondiscrimination Act of 2008 (FINA) regulations, answering this question is optional and your response, or non-response, will not impact any rewards or incentives that may be associated with completion of this HRA. If you choose not to answer this question, please select the "I do not know" answer.

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