LOS ANGELES COUNTY - DEPARTMENT OF HEALTH SERVICES
HUMAN RESOURCES
Please take a few minutes to complete this questionnaire, and use the passcode provided to you from personnel. Please complete this questionnaire in PEN or ONLINE and present to the staff at the examination clinic or prior to your appointment. To protect your confidentiality, it should not be given or shown to anyone else. On the day of your appointment, you must bring a valid driver's license or other form of identification which has both your photograph and signature.
And review your answers carefully before submitting, the data will not be saved if you quit in the middle before it completes. You could though re-enter this form again later as you wish,
Once the form has been submitted, you will not be able to alter any changes made to your responses, for you are not allowed to log back
into this form again.
