ARIZONA INTERSCHOLASTIC ASSOCIATION7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552

PHONE: (602) 385-3810

The Preferred Urgent Care of the Arizona Interscholastic Association

2020-21 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION

Name: __________________________________________ Date of Birth: ____________________________________________

Age: ____________________________________________ Sex: ____________________________________________________

Height: _________________________________________ Weight: _________________________________________________

% Body Fat (optional): ____________________________ Pulse: ___________________________________________________

BP: ____ / ____ (____ / ____,____ / ____)

Vision: R20/____ L20/____ Corrected: Y N

Pupils: Equal Unequal

Normal Abnormal Findings Initials *

MedicalAppearance

Eyes/Ears/Throat/Nose

Hearing

Lymph Nodes

Heart

Murmurs

Pulses

Lungs

Abdomen

Genitourinary &

Skin

MusculoskeletalNeck

Back

Shoulder/Arm

Elbow/Forearm

Wrist/Hands/Fingers

Hip/Thigh

Knee

Leg/Ankle

Foot/Toes

* - Multi-examiner set-up only& - Having a third party present is recommended for the genitourinary examination

NOTES:

Cleared Without Restriction

Cleared With Following Restriction: ___________________________________________________________________________________

Not Cleared For: All Sports Certain Sports: ___________________________ Reason: ____________________________

Recommendations: __________________________________________________________________________________________________

Name of Physician (Print/Type): ___________________________________________________ Exam Date: ____________________________

Address: _______________________________________________________________________ Phone: ________________________________

Signature of Physician: __________________________________________________________, MD/DO/ND/NMD/NP/PA-C/CCSP

FORM 15.7-B 01/14/2019 (rev.) NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.

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