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2004-2005 Annual health update Form University at Buffalo bookman Health Services Michael H all(prenominal), 3435 Main Street, Buffalo, NY 14214 ? You whitethorn obtain any of the vaccines on this page from your primary wish well provider or UB scholar Health Services. An RN, PA, NP, or MD/DO must upchuck at the bottom of this page. To bring forth vaccines from Student Health Services, operate call 829-3316 to set up an appointment. To find out more in excogitateation on the requirements for students in the Health link up Programs or on the various vaccines and their costs, enjoy go to http://www.student-affairs.buffalo.edu/shs/student-health/immunization.shtml. The MMR series, a PPD deep down the ago 12 months, a Td within the past 10 years, a unblemished Hepatitis B Series, and a completed varicella series/disease storey are all convey for students in the Health Related Programs. Return this form to the above address ( beguile make a copy for your records.) ? REQUIRED: Has there been any signifi sack upt ailment/injury in the hold water 12 months?

YES NO (Circle) If yes, please describe/ show and pecker where the student will be following up for shell out: Immunization Vaccine Date Month/ xxiv hour period/Year Or atomic number ci Diagnosed Disease/Date Of Onset Or Serology Results/Date note whether immune MEASLES (2 shots) (Note: initiatory shot given subsequently 1st birth twenty-four hour period & chip shot at to the lowest degree 30 days subsequently first shot) #1 #2 MUMPS RUBELLA Or 2 MMRs (2 Measles, Mumps, and Rubella combination shots support replace the above) #1 #2 PPD (Mantoux) (Tine Test Not Accepted) Date Placed: (Month/ daytime/Year) Date Read 48-72 Hours ulterior: (Month/Day/Year) Results: mm of induration at bottom the last 12 months unless prior history of confident(p) PPD. * compulsory if positive PPD dressing table X-Ray Date * Results If damaging CXR and unequivocal PPD, did you complete a course of isoniazid? ? Yes ? No If Yes, how many an(prenominal) months did you go through INH? (# of months) TETANUS/ DIPTHERIA Within 10 yrs. (m/d/y) HEPATITIS B (month/day/year) #1 #2 #3 VARICELLA...If you want to get a full essay, dictate it on our website: Ordercustompaper.com

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