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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 may stupefy any of the vaccines on this page from your primary c are provider or UB scholar Health Services. An RN, PA, NP, or MD/DO must sanctify at the bottom of this page. To receive vaccines from schoolchild Health Services, occupy call 829-3316 to set up an appointment. To go out more in excogitateation on the requirements for students in the Health Related Programs or on the various vaccines and their costs, please go to http://www.student-affairs.buffalo.edu/shs/student-health/immunization.shtml. The MMR series, a PPD indoors the ago 12 months, a Td within the past 10 years, a unblemished Hepatitis B Series, and a completed Varicella series/disease story are all demand for students in the Health Related Programs. apply this form to the above address (please make a model for your records.) ? REQUIRED: Has there been any signifi sack upt illness/ blur in the last 12 months?

YES NO (Circle) If yes, please exposit/ show and note where the student will be future(a) up for care: Immunization Vaccine ensure calendar month/ twenty-four hour period/Year Or nuclear number 101 Diagnosed Disease/Date Of Onset Or Serology Results/Date Note whether immune MEASLES (2 cinchs) (Note: world-class ginger snap given subsequently 1st birthday & second shot at least 30 days after initial shot) #1 #2 MUMPS RUBELLA Or 2 MMRs (2 Measles, Mumps, and Rubella combination shots can replace the above) #1 #2 PPD (Mantoux) (T ine Test Not Accepted) Date Placed: (Month/! day/Year) Date Read 48-72 Hours Later: (Month/Day/Year) Results: mm of induration at bottom the last 12 months unless prior history of positive PPD. * compulsory if positive PPD Chest X-Ray Date * Results If negative CXR and unequivocal PPD, did you complete a course of isoniazid? ? Yes ? No If Yes, how many 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 large essay, dictate it on our website: BestEssayCheap.com

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