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Get UConn Student Health History Form 2019-2024

ITTED BY AUGUST 1 FOR FALL SEMESTER AND NOVEMBER 1 FOR SPRING SEMESTER Student Last Name: Student First Name: Student Middle Name: Pronouns: Sex Assigned at Birth: Date of Birth: Gender Identity: Net ID: Preferred Name: MM/DD/YYYY IMMUNIZATION HISTORY 1. MEASLES, MUMPS, RUBELLA (MMR) Vaccination - required of all students born after 1957 OPTION 1: OPTION 2: Measles, Mumps, Rubella (MMR) Vaccination Dose #1 Dose #2 (First dose must be given on or after your first birthday to be accepted.

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