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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