The Preferred Health Care
Partner of the Arizona
Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 North 18th Street, Phoenix, Arizona 85020-5552
Phone: (602) 385-3810
2016-2017 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION
Name:
Date of Birth:
Age:
Sex:
Height:
Weight:
% Body fat (optional):
Pulse:
BP:____ /____ (____ /____,____ /____)
Vision:
R20/_____
L20/_____
Pupils:
Equal_____
Unequal____
Normal
Corrected: Y___ N___
Abnormal Findings
Medical
Appearance
Eyes/Ears/ Throat/Nose
Hearing
Lymph Nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary †
Skin
Musculoskeletal
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
NOTES:
* Multi-examiner set-up only.
† Having a third party present is recommended for the genitourinary examination.
Cleared Without Restriction
Not Cleared For:
All Sports
Recommendations:
Certain Sports
Reason:
Name of Physician(Print/Type):
Exam Date:
Address:
Phone:
Signature of Physician:
, MD/DO/ND/NMD/NP/PA-C/CCSP
FORM 15.7-B
03/12 NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
Initials*
1-888-364-7502
NextCareAZ.com
The Preferred Health Care Partner of the
Arizona Interscholastic Association
N. R d 1 E
89
Frye Road
10
E. Florence Blvd.
W. Van Buren St.
Safeway
Walgreens
W. Rd 2 N
Chandler Blvd.
Dobson Road
Ironwood Drive
Bank of
America
County Rd.
Fry’s
N. Arizola Rd.
Walgreens
W. McDowell Rd.
60
E. Cottonwood Ln.
N. Dysart Rd.
Southern Avenue
N. Litchfield Rd.
Meridian Road
N. Verbena Henness Rd.
W. Indian School Rd.
Broadway Road
Pecos Road
W. Rd 1 N
E. Rd 1 N
Chino Valley
High School
89
Center St.
Apache Junction • 85120
Avondale • 85392
Casa Grande • 85122
Chandler • 85224
Chino Valley • 86323
2080 West Southern Ave., Suite #A1
13075 W. McDowell Rd., Suite #D106
1683 E. Florence Blvd., Suite #7
600 S. Dobson Road, Suite #C-26
474 State Highway 89
Walmart
99¢ Store
mbu
W. Cottonwood St.
s Av
enu
e
W. Dunlap Ave.
17
Cottonwood • 86326
Flagstaff • 86001
Glendale • 85302
450 S. Willard Street, Suite #120
1000 N. Humphreys St., Suite #104
10240 N. 43rd Ave., Suite #3
d.
Blv
Kmart
e.
Av
Walmart
McKellips Dr.
95
ASU West
Campus
ark
W. Glendale Ave.
Glendale • 85306
5410 W. Thunderbird Road, Suite #101
9494 W. Northern Ave.
E. McKellips Rd
60
Baseline Road
202
E. Brown Rd
Red Mountain
High School
Mesa • 85203
Mesa • 85204
Mesa • 85205
18589 N. 59th Ave., Suite #101
1810 Mesquitee PAve., Suite B
535 E. McKellips Road, Suite #101
3130 E. Baseline Road, Suite #105
1066 N. Power Road, Suite #101
Beardsley Rd.
E. Oak St.
ia
Dr
.
Albertson’s
17
W. Northern Ave.
Indian School
Arcadia H.S.
N. 19th Ave.
E. Thomas Rd.
101
51
48th St.
(91st Ave.)
(99th Ave.)
Lake Pleasant Road
Greenfield
Val Vista
Walmart
Walgreens
Phoenix
Children’s
Hospital
Safeway
N. 21st St.
McKellips
Bashas
N. 16th St.
McDowell
E. Osborn Rd.
N. A
rca
d
N. 20 th St.
Rose Garden Ln.
LOOP
202
N. 44th St.
leasa
nt Pkwy
W. Orangewood Ave.
Mesa • 85215
Peoria • 85382
Phoenix • 85016
Phoenix • 85018
Phoenix • 85021
4401 E. McKellips Road, Suite #102
20470 N. Lake Pleasant Rd., Suite #102
1701 E. Thomas Road, Suite #A104
4730 E. Indian School Rd., Suite #211
8101 N. 19th Ave., Suite #A
20470 N. Lake Pleasant Rd.
Suite 102
N. 7th Ave.
Lake Havasu City • 86403
k
La
Glendale • 85308
8101 N. 19th Avenue, Ste. A
Phoenix, AZ 85021
N. 35th Ave
N. 43rd Ave
N. 51st Ave
N. 59th Ave
H
Peoria/Glendale
9494
W. Northern Ave., Suite #101
N. Lindsay Rd.
Wheeler
Park
N. Horne
nter Ln
L
n
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Starbucks
n
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Glendale • 85305
202
N. Mesa Dr.
Civic Ce
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W. Union Hills Dr
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N. 59th Ave
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101
10240 North 43rd Avenue,
Ste #3
Glendale, AZ 85302
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W. Thunderbird Rd
N. Power Rd
Colu
101
N. Val Vista Dr.
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Dana Park
W.
Peoria Ave.
Ave
W. Northern Ave.
S. 32nd St.
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Target
101
N. 91st Ave.
Des
N. 99th Ave.
N. 51st Ave.
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N. 43rd Ave.
180
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N. 55th Ave
W. Greenway Rd
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Center
17
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Stu
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89A
2530 W. SR 89A
Sedona, AZ 86336
(Arizona 89A & Andante Dr.)
1-888-364-7502
NextCareAZ.com
450 S. Willard Street, Suite 120
Cottonwood, AZ 86326
(Arizona 89A at Willard Street)
The Preferred Health Care Partner of the
COTTONWOOD
Arizona Interscholastic Association
Tucson •
4280 North Oracle Rd., Suite #100
W
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a
N. 91st Ave.
Ave
N. 99th
Col o n n
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Albertson’s
Market
N. Navajo Dr.
N. Windsong Dr.
Curry Road
Jack in
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Rd
3051 N. Windsong Dr.
Prescott Valley, AZ 86314
(E. Florentine Rd & Windsong Dr.)
PRESCOTT VALLEY
Rural
Ro
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Re
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Tucson • 85706
5369
CalleSanta
Santa
Cruz
5369 S. Calle
Cruz,
Suite #145
Suite 145, Tucson, 85706
ms
N.
Surprise • 85374
Tempe • 85281
14800 W. Mtn. View Blvd., Suite #100
914 N. Scottsdale Rd., Suite #104
Sun City, 85351
TUCSON
Speedway Blvd.
Tucson
• 85712
6238 E. Pima
St.
6238 E. Pima Street
Tucson
Speedway
Metro
Wildcat
E. 6th St.
Tucson • 85719
501 North Park Ave., Suite #110
501 N. Park Ave., Ste. 110
E. Old Span
ish T
rail
E 22nd St
Target
S Harrison Rd
10
University Blvd.
Starbucks
N. Park Ave.
Circle K
10
Harkins
69
W
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9745
9745W.
W.Bell
BellRoad,
Road,Suite
Suite #105
105
Pima
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W. Miracle Mile
4280 N. Oracle Rd. Ste. 100
Tucson, 85705
AZ 85705
(E. Florentine Rd & Windsong Dr.)
Sun City • 85351
10
W. Valencia Rd.
E. Florentine Rd.
N. Glassford Hill Rd.
Willow Creek Rd.
W. Drexel Rd.
60
W Bell Rd.
N. Euclid Ave.
Walgreens
Prescott
Valley, AZ 86314
3051 N. Windsong
Drive
ra
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Bo
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W. Thunderbird Rd.
86
19
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3051 N.•Windsong
Prescott Valley
86314 Dr.
PRESCOTT VALLEY
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& Suites
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Wilmot
W. Irvington Rd.
W. Limberlast Dr.
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69
202
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S. C
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W. Wetmore Rd.
W. Prince Rd.
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101
Rd.
86
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Cru
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77
S. Midvale Park Rd.
10
.M
101
Sedona
• 86336
2530 W. SR 89A
2530 W. SR 89A, Suite #A
Sedona, AZ 86336
(Arizona 89A & Andante Dr.)
N. Robert Rd.
WOOD
N. Oracle Rd.
reet, Suite 120
Z 86326
Willard Street)
N. Flowing Wells Rd.
7425 E. Shea Blvd., Suite #108
N. Windsong Dr.
Ca
89A
N. 98th Ave.
.
Stutz Bearcat Dr.
E. Mountain View Rd
Scottsdale • 85260
Blue Heron Way
89A
101
PRESCOTT
W
W. Union Hills Dr.
Rd
Rigby
Andante Dr.
N. 74th St
N. Scottsdale Rd
70th
rd St.
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SN.
ay
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lva
Rd
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N. Ha
S.
E. Shea Blvd
2062
Willow Creek
Rd.
Prescott
• 86301
Prescott,
AZ 86301
2062 Willow
Creek Road
(Green Ln. & Willow Creek Rd.)
Scottsdale Road
Phoenix, AZ 85035
Harkins Theaters
.
Rd
20950 N. Tatum Blvd., Suite #190
69
N. RobertN.Rd.
Robert Rd.
ey
all
rV
101
Phoenix • 85050
SEDONA
20950 N Tatum Blvd, Suite 190, Phoenix, AZ 85050
5920
Road
5920W.
W. McDowell
McDowell Rd,
E. Florentine Dr.
lle
Phoenix • 85035
3229 E. Greenway Rd., Suite #102
E. Lakeshore
Dr.
E. Florentine
Rd.
Mi
101
Green Ln.
N. Tatum Blvd.
7-11
Greenway Rd.
Phoenix
• 85032
E. Thunderbird Rd.
.
DESERT RIDGE
MARKET PLACE
E. Rose Garden Ln.
N. 59th Ave.
Food City
y Rd
Walgreens
W. McDowell Rd.
N. 40th St.
N. 32nd St.
51
Valle
N. Glassford Hill Rd.
eer
N. Windsong Dr.
E. D
Willow Creek Rd.
W. Coronado Rd.
E. Bell Rd.
9525 E.•Old
Spanish Trail
Tucson
85748
9525
E. Old Spanish Trail, Suite #101
Tucson