UNIVERSITY PEDIATRICS
UNIVERSITY PEDIATRICS
101 W.T. Harris Blvd. 5435 Prosperity Church Rd 10545 Blair Rd.
Bldg. 1000 Suite 1121 Suite 1500 . Suite 3200
Charlotte NC 28262 Charlotte, NC 28269 Mint Hill, NC 28227
Phone (704) 717-2000 Phone (704) 863-9910 Phone (704) 863-9550
Fax (704) 863-9741 Fax (704) 863-9891 Fax (704) 863-9551
_______________________________________ is a regular patient under my care
Immunizations are up to date by current recommendations. There are no health problems to limit participation in nursery, school, camp, or athletics except as noted below.
Date of last physical _____________________________________
Weight___________ Height____________ Blood Pressure_____________
Vision (R) ________ (L) ________ Hearing ______________
Allergies: _______________________________________________________________
Medication & Indications: ________________________________________________
Significant health problems and/or limitations to normal activities: ______________
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Immunization Record: See Attached Sheet.
_______________________________________________ __________________
Date
Bryan Adams, MD Shellee Higgins, MD Rebecca Takahashi, MD
Michael Bean, MD Heather Knutson, MD Janelle White, MD
Erica Berger, MD Christopher Lakin, MD Monique Sutton, CPNP
Karen Breach, MD Tara Lods, MD Mary White, CPNP
Kevin Freeman, MD Amanda McDowell, MD
Andrew Gunter, MD Kathleen Reardon, MD
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