Student Health History Form 
Note: This is a printable form; it cannot be completed and submitted on-line.
University policies require that you submit your health and immunization history before July 15 for the fall semester and before December 15 for the spring semester.
A Health History Form is part of the Orientation packet that is mailed to each freshman or transfer student. If you did not receive this packet, please print and complete the entire form from the link above, or contact the Office of Orientation Services at (860) 486-4866.
Note: Students enrolled in the Medical, Dental or Graduate schools at UCHC in Farmington should contact their school for health history requirements as they may differ from those stated here.
For more information on immunization requirements, click here.
Women's Clinic Health History
If you have scheduled an appointment with our Women’s Clinic, you may have been instructed to print and complete this form. Please bring it with you to your appointment. This form contains some very explicit questions that help our clinicians in evaluating your health risks. You are not obligated to answer any questions which make you feel uncomfortable.
Immunization Exemption Form
If you require exemption from the university's immunization requirements, please print, complete and return this form. Please note that if your request exemption for either medical or religious reasons, you may be excluded from campus in the event of an outbreak of a disease for which immunizations are required.
For more information on immunization exemptions, click here.
Authorization for Release of Health Information
If you need to have a copy of your Student Health Services medical record sent to another medical provider, please print and complete this release of information form. You will need to provide your name and other identifying information as outlined on the form, the type of information you need and where/to whom you would like it sent. Your request will be processed within 2 weeks of receipt. Please be sure to include your telephone number in the event we need to contact you.
Print, complete and mail/fax the form as indicated on the form. (To respect your privacy, we discourage the faxing of information.)
Meningitis Vaccination Permission Form
If you have signed up to attend one of Student Health Service's meningitis vaccination clinics and will be under 18 years of age at the time of vaccination, the signature of your parent or guardian is required.
Note: You must reserve a dose of vaccine at our Meningitis Clinic page if you plan on receiving your meningitis vaccination from us)
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