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Health Background Form 健康背景信息表

In the USA, students are normally required to file a Health Background Report (in form or statement) with the university when they are enrolled. It is used solely as an aid to providing health care while they are at the university. The report usually includes three major parts: Medical History, Immunization History and Physical Examination. The following is a

sample of part 1.

University at Buffalo Student Health Services

Michael Hall, 3435 Main Street

Buffalo, NY 14214

Instructions:

The UB Student Wellness Team (Health, Counseling, and Wellness Education Services) welcomes you to UB! Please visit our website above for information on how we can assist you in achieving your goals while you are a student at the University. First, we'd like to help you comply with several requirements.

All Students Must Complete The Following Steps (a check-off list is provided below):

Student (or Parent/Guardian if under 18): Complete Part 1 “Demographics & Permissions”

Student: Complete Part 2 “Health History”

Student (or Parent/Guardian if under 18): Complete Part 3 “Meningitis Information Response Area”

Primary care medical provider: Complete Part 4 “Physical Exam”

Primary care medical provider: Complete Part 5 “Immunizations”

Student: Please Make A Copy Of This Completed Form For Your Personal Records Prior To Submitting It To Ub.

Student: Return completed form to UB Student Health Services in the enclosed pre-addressed envelope marked “confidential” or mail to the above address.

The State University of New York at Buffalo requires that each student file the Health Background Form with the UB Student Health Services before attending the University. Only the immunization records may affect your enrollment status at the University. The information you provide will be used to assist with your health care while you are enrolled as a student. The information on this form is subject to strict confidentiality policies. Students desiring religious exemption from any vaccine requirement(s) must call 716-829-3316 ext. 213 for further instructions.

2004-2005 Health Background Form

University at Buffalo Student Health Services

Michael Hall, 3435 Main Street, Buffalo, NY 14214

Part 1: Demographics & Permissions (Student To Complete)

1. Full Name:

2. Date of Birth:

3. Social Security # or UB Person #:

4. Address (Local or Permanent):

5. Local/Permanent Phone:

6. Emergency Contact Name:

7. Emergency Contact Phone #:

8. If student under 18 years of age, signature of parent or guardian indicates that UB Student Health Services has permission to treat your child:

Parent/Guardian Signature: Date:

9. I realize that email is not a secure media. However, in order to facilitate communication, I give Student Health Services permission to communicate with me via email about my care. I realize that I can withdraw this permission in writing at any time.

Student Signature: Date:

Part 2: Health History (Student to complete)

1. Drug Allergies:

2. Current Medications & doses:

3. Medical/Psychological conditions:

4. Family's Medical/Psychological conditions:

Part 3: Meningitis Information Response Area (Student To Complete)

Please read fact sheet on page 4, then check & complete 1 of the 2 boxes below:

I have (or for students under age 18) my child has:

had the meningococcal meningitis immunization (Menomune?) within the past 10 years.

Date received: (notation of month/day/year is required for this option)

read, or have had explained to me, the information regarding meningococcal meningitis disease (please read page four of this Health Background Form “Meningococcal Meningitis Fact Sheet”). I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease.

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