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2004-2005 Annual wellness Update Form University at buffalo bookman Health Services Michael H all(prenominal), 3435 Main Street, Buffalo, NY 14214 ? You may induce any of the vaccines on this page from your primary c be supplier or UB scholar Health Services. An RN, PA, NP, or MD/DO must sanctify at the bottom of this page. To receive vaccines from student Health Services, occupy call 829-3316 to set up an appointment. To amaze 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 within the ago 12 months, a Td within the past 10 years, a unblemished Hepatitis B Series, and a completed Varicella series/disease biography are all demand for students in the Health Related Programs. unsay this form to the above address (please make a written matter for your records.) ? REQUIRED : Has there been any signifi sack upt illness/ brand in the last 12 months? YES NO (Circle) If yes, please come across/ show and note where the student will be side by side(p) up for care: Immunization Vaccine leave month/ twenty-four hour period/Year Or atomic number 101 Diagnosed Disease/Date Of Onset Or Serology Results/Date Note whether immune MEASLES (2 tantrums) (Note: world-class throw given subsequently 1st birthday & second shot at least 30 days after start-off shot) #1 #2 MUMPS RUBELLA Or 2 MMRs (2 Measles, Mumps, and Rubella combination shots can replace the above) #1 #2 PPD (Mantoux) (Tine 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 m any months did you go through INH? (# of mo! nths) lockjaw/ DIPTHERIA Within 10 yrs. (m/d/y) HEPATITIS B (month/day/year) #1 #2 #3 VARICELLA...If you want to get a salutary essay, dictate it on our website: BestEssayCheap.com

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