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 so an w S Starbucks n oP Glendale • 85305 202 N. Mesa Dr. Civic Ce . vd Bl ri N ch lo ul cC .M ar y W. Union Hills Dr e. Av p Ca es M 95 te Lib r N. 51st Ave N. 59th Ave N. 67th Ave Honeywell i qu Havasu Regional Medical Center Riviera B lvd 101 10240 North 43rd Avenue, Ste #3 Glendale, AZ 85302 LOOP se W. Thunderbird Rd N. Power Rd Colu 101 N. Val Vista Dr. nue Dana Park W. Peoria Ave. Ave W. Northern Ave. S. 32nd St. ilva Target 101 N. 91st Ave. Des N. 99th Ave. N. 51st Ave. ave r Str eet rd St. S. W illa 180 N. H Stre umph rey et s yW ay Ca lva r oa d. yR rk R d 89A W. W. Olive Ave. 17 N. Recker Rd W. Cactus Rd. Pa rd rbi de un Th N. For t Valle a Airp S. Basha’s N. 43rd Ave. 180 N. B e 89A N. 55th Ave W. Greenway Rd Flagstaff Medical Center 17 B Stu S. Ca l 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 ay a N. 91st Ave. Ave N. 99th Col o n n de dA ve Albertson’s Market N. Navajo Dr. N. Windsong Dr. Curry Road Jack in the Box LOOP rV lle Mi ey all . Rd 3051 N. Windsong Dr. Prescott Valley, AZ 86314 (E. Florentine Rd & Windsong Dr.) PRESCOTT VALLEY Rural Ro ad Re e 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 .G 9745 9745W. W.Bell BellRoad, Road,Suite Suite #105 105 Pima N. Navajo Dr. 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 n Bo ule W. Thunderbird Rd. 86 19 nta in Vie w 3051 N.•Windsong Prescott Valley 86314 Dr. PRESCOTT VALLEY Hampton Inn & Suites va rd Wilmot W. Irvington Rd. W. Limberlast Dr. ou 69 202 a S. C W. Ajo Way W. Wetmore Rd. W. Prince Rd. k Rd. 1 w Creek Rd.) 101 Rd. 86 z Cru anta lle S 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. illaSt .W SN. ay ry W lva Rd yden 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