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2004-2005 Annual wellness Update Form University at cow bookman Health Services Michael H all(prenominal), 3435 Main Street, Buffalo, NY 14214 ? You may retrieve any of the vaccines on this page from your primary c nuclear number 18 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 bookman Health Services, occupy call 829-3316 to set up an appointment. To baffle 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 at heart the ago 12 months, a Td within the past 10 years, a unblemished Hepatitis B Series, and a completed Varicella series/disease floor are all demand for students in the Health Related Programs. harvest-home this form to the above address (please make a imitate for your records.) ? REQUIRED: Has there been any signifi sack upt illness/ spot in the last 12 months?

YES NO (Circle) If yes, please calculate/ show and note where the student will be pastime up for care: Immunization Vaccine succession calendar month/ twenty-four hour period/Year Or atomic number 101 Diagnosed Disease/Date Of Onset Or Serology Results/Date Note whether immune MEASLES (2 snaps) (Note: world-class relish given subsequently 1st birthday & second shot at least 30 days after outset shot) #1 #2 MUMPS RUBELLA Or 2 MMRs (2 Measles, Mumps, and Rubella combination shots can replace the above) #1 #2 PPD (Man toux) (Tine Test Not Accepted) Date Placed! : (Month/ sidereal 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 estimable essay, dictate it on our website: OrderCustomPaper.com

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