7-2018 annual preparticipation physical examination · 3130 e. baseline road, suite #105 60 n....
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ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Street, Phoenix, Arizona 85020-5552
Phone: (602) 385-3810
2017-2018 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION
The Preferred Urgent Care of the Arizona Interscholastic Association
Name: Sex: Age: Date of Birth:
Height: Weight:% Body fat (optional):
Pupils:
Pulse:
BP:____/____ (____ /____,____/____)
Corrected: Y___ N___Vision: R20/_____ L20/_____
Normal Abnormal Findings Initials*
Medical
Musculoskeletal
Appearance
Lymph Nodes
Back
Pulses
Wrist/Hand/Fingers
Eyes/Ears/ Throat/Nose
Heart
Shoulder/Arm
Lungs
Hip/Thigh
Genitourinary †
Leg/Ankle
Hearing
Neck
Murmurs
Elbow/Forearm
Abdomen
Knee
Skin
Foot/Toes* Multi-examiner set-up only.† Having a third party present is recommended for the genitourinary examination.
NOTES:
Recommendations:
Name of Physician(Print/Type):
Address:
Signature of Physician:
FORM 15.7-B 03/12
Exam Date:
Phone:
, MD/DO/ND/NMD/NP/PA-C/CCSP
Cleared Without RestrictionNot Cleared For: All Sports Certain Sports Reason:
Equal_____ Unequal____
NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
1-888-364-7502NextCareAZ.com
Apache Junction • 851202080 West Southern Ave., Suite #A1
Broadway Road
Mer
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Ironw
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Driv
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Southern Avenue
60
Walgreens
Avondale • 8539213075 W. McDowell Rd., Suite #D106
W. McDowell Rd.
W. Van Buren St.
W. Indian School Rd.
N. D
ysart Rd.
N. Litch�eld Rd.
Fry’s
Casa Grande • 851221683 E. Florence Blvd., Suite #7
10
E. Florence Blvd.
E. Cottonwood Ln.
N. A
rizola Rd.
County Rd.
N. Verbena H
enness Rd.
99¢ Store
Bank ofAmerica
Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26
Pecos Road Dob
son
Roa
dFrye Road
Chandler Blvd.
Glendale • 853065410 W. Thunderbird Road, Suite #101
W. Greenway Rd
N. 5
9th
Ave
N. 5
1st A
ve
N. 4
3rd
Ave
W. Thunderbird RdASU West Campus
Thunderbird Paseo Park
N. 3
5th
Ave
17N. 5
5th
Ave
H
Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302
W. Cactus Rd.
Peoria Ave.
N. 5
1st A
ve.
N. 4
3rd
Ave.
W. Dunlap Ave.
17
17
Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.
W. Olive Ave.
W. Northern Ave.N. 9
9th
Ave.
N. 9
1st A
ve.
W. Glendale Ave.
101
101
Target
Mesa • 852051066 N. Power Road, Suite #101
E. Brown Rd
Red MountainHigh School
N. P
ower
Rd
202
N. R
ecke
r Rd
E. McKellips Rd
Mesa • 852043130 E. Baseline Road, Suite #105
60
Baseline Road
N. L
inds
ay R
d.
N. V
al V
ista
Dr.
S. 3
2nd
St.
Dan
a Pa
rk
Mesa • 85203535 E. McKellips Road, Suite #101
McKellips Dr.
N. M
esa
Dr.
N. H
orne
LOOP202
Walmart
Cottonwood • 86326450 S. Willard Street, Suite #120
89AS. Calv
ary W
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Willa
rd St
.
W. Cottonwood St.
Airpark Rd.
89A
Glendale • 8530818589 N. 59th Ave., Suite #101
N. 59th Ave
W. Union Hills Dr
Honeywell
101
N. 51st Ave
N. 67th Ave
Starbucks
Chino Valley • 86323474 State Highway 89
Safeway
89
89
W. Rd 1 N E. Rd 1 N
W. Rd 2 N
N. R
d 1
E
Walgreens
Center St.
Chino ValleyHigh School
Flagstaff • 860011000 N. Humphreys St., Suite #104
180
180
N. F ort Valley Road
N. H
umph
reys
St
reet
W. Columbus Avenue
W. Desilva Avenue
Basha’sN
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ver S
tree
t
Flagstaff MedicalCenter
Lake Havasu City • 864031810 Mesquite Ave., Suite B
Kmart95 Mesqu
ite A
ve.
N. McC
ulloch
Blvd.
Rivi
era
Blv
d
Capri Blvd.Library Ln
Civic Center Ln
95
Swanso
n Ave.
WheelerPark
Havasu RegionalMedical Center
Mesa • 852154401 E. McKellips Road, Suite #102
LOOP202
McKellipsVal V
ista
Gre
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ld
McDowell
Walmart
Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102
Rose Garden Ln.
Beardsley Rd.
Lake
Ple
asan
t Roa
d(9
9th
Ave.
)
(91s
t Av
e.)
101
20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382
LakePleasant Pkwy
Bashas
Walgreens
Phoenix • 850161701 E. Thomas Road, Suite #A104
51
E. Oak St.
E. Thomas Rd.
E. Osborn Rd.
N. 16th St.
N. 21st St.
N. 20 th St.
PhoenixChildren’sHospital
Phoenix • 850184730 E. Indian School Rd., Suite #211
N. A
rcad
ia Dr.
Indian School
N. 4
4th
St.
48th
St.
Arcadia H.S.
Safeway
Phoenix • 850218101 N. 19th Ave., Suite #A
8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021
W. Northern Ave.
W. Orangewood Ave.N. 1
9th
Ave.
N. 7
th A
ve.
17
Albertson’s
The Preferred Health Care Partner of the Arizona Interscholastic Association
Phoenix • 8505020950 N. Tatum Blvd., Suite #19020950 N Tatum Blvd, Suite 190, Phoenix, AZ 85050
E. Deer Valley Rd.
N. T
atum
Blv
d.
E. Rose Garden Ln.DESERT RIDGEMARKET PLACE
101101
Scottsdale • 852607425 E. Shea Blvd., Suite #108
N. S
cott
sdal
e Rd
E. Shea Blvd
Harkins Theaters
N. H
ayden Rd
E. Mountain View Rd
N. 7
0th
St
101
N. 7
4th
St
Sun City • 853519745 W. Bell Road, Suite #1059745 W. Bell Road, Suite 105
Sun City, 85351
W. Union Hills Dr.
W Bell Rd.N. 9
9th
Ave
N. 9
8th
Ave
.
N. 9
1st
Ave.
W. Thunderbird Rd.
101
101
Tempe • 85281914 N. Scottsdale Rd., Suite #104
Curry Road
Scot
tsda
le R
oad
LOOP202
Jack inthe Box
Rura
l
Tucson • 857126238 E. Pima Street
Pima
SpeedwayW
ilmot10
6238 E. Pima St. Tucson
Circle K
Tucson • 857489525 E. Old Spanish Trail, Suite #101
E. Old Spanish Trail
E 22nd St
S Ha
rriso
n Rd
9525 E. Old Spanish Trail Tucson
Target
Starbucks
Tucson • 857054280 North Oracle Rd., Suite #100
W. Wetmore Rd.
W. Prince Rd.
W. Miracle Mile
N. O
racl
e Rd
.
N. F
low
ing
Wel
ls R
d.
10
4280 N. Oracle Rd. Ste. 100Tucson, AZ 85705
77
Walgreens
W. Limberlast Dr.
Tucson • 857065369 S. Calle Santa Cruz, Suite #145
W. Ajo Way
W. Valencia Rd.
W. Drexel Rd.
W. Irvington Rd.
S. M
idva
le P
ark
Rd.
S. C
alle
San
ta C
ruz R
d.
10
86 86
5369 S. Calle Santa Cruz Suite 145, Tucson, 85706
Harkins
19
Tucson • 85719501 North Park Ave., Suite #110
E. 6th St.
Speedway Blvd.
University Blvd.
N. E
uclid
Ave
.
10
N.P
ark
Ave.
TUCSON
501 N. Park Ave., Ste. 110
MetroWildcat
Sedona • 863362530 W. SR 89A, Suite #A
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89A
89A
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Miller Valley Rd.
Willow
Creek R
d.
N. G
lass
ford
Hill
Rd.
N. N
avaj
o D
r.
N. R
ober
t Rd.
N. W
inds
ong
Dr.
450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)
2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)
2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)
3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)
69
E. Florentine Rd.
Prescott • 863012062 Willow Creek Road
89A
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COTTONWOOD
PRESCOTT PRESCOTT VALLEY
89A
89A
Green Ln.
Miller Valley Rd.
Willow
Creek R
d.
N. G
lass
ford
Hill
Rd.
N. N
avaj
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r.
N. R
ober
t Rd.
N. W
inds
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Dr.
450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)
2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)
2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)
3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)
69
E. Florentine Rd.
Prescott Valley • 863143051 N. Windsong Drive
N. W
inds
ong
Dr.
N. R
ober
t Rd.
69
E. Florentine Dr.
E. Lakeshore Dr.
Phoenix • 850323229 E. Greenway Rd., Suite #102
51
E. Thunderbird Rd.
Greenway Rd.
E. Bell Rd.
N. 32nd St.
N. 40th St.
Food City
Phoenix • 850355920 W. McDowell Road
W. McDowell Rd.
W. Coronado Rd.
N. 59th Ave.
5920 W. McDowell Rd, Phoenix, AZ 85035
7-11
Walgreens
Surprise • 8537414800 W. Mtn. View Blvd., Suite #100
60
N. Reem
s Road
W. Mountain View Boulevard
Hampton Inn & Suites
Albertson’sMarket
W. Grand Ave
Colon n ade Way
1-888-364-7502NextCareAZ.com
The Preferred Health Care Partner of the Arizona Interscholastic Association