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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download