Medical History Form 4Medical History Form 4
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PURDUE UNIVERSITY STUDENT HEALTH CENTER

MEDICAL HISTORY FORM

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Please PRINT - This form must be completed in English and signed by (1) a medical provider or personal recordkeeper, and
(2) the student (parent or guardian if student is under age 18)
Individuals born before 1957 are considered immune to measles, mumps and rubella, but a booster of Tetanus/diphtheria (Td)
must have been received in the last 10 years
All immunizations must have been received after 1968
Individuals seeking a medical or religious exemption must submit a letter of request to the Director of the Student Health Center
signed by the student (parent/guardian if student is under the age of 18)

Last Name:_____________________________First: __________________________ Middle:________________
Purdue ID #: ________________________ Date of Birth: _____________ International Domestic 
Emergency contact name and phone #:____________________________________________________________
Important: include MONTH /