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

2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

(The Parent or Guardian should fill out this form with assistance from the student athlete.)

Exam Date:
In case of emergency, contact:

Name:
Sex:

Name:

Age:

Relationship:

Date of Birth:

Phone (Home):

Grade:

(Work):

School:

(Cell):

Sport(s):
Address:

Name:

Phone:

Relationship:

Personal Physician:

Phone (Home):

Hospital Preference:

(Work):

Explain "Yes" answers on following page.

Circle questions you dont know the answers to.

(Cell):
Y

1) Has a doctor ever denied or restricted your participation in sports for any reason?
2) Do you have an ongoing medical condition (like diabetes or asthma)?
3) Are you currently taking any prescription or nonprescription (over-the-counter) medicines or supplements?
(Please specify):
4) Do you have allergies to medicines, pollens, foods, or stinging insects?
(Please specify):
5) Does your heart race or skip beats during exercise?
6) Has a doctor ever told you that you have (check all that apply):
High Blood Pressure

A Heart Murmur

High Cholesterol

A Heart Infection

7) Have you ever spent the night in the hospital?

8) Have you ever had surgery?

* 9) Have you ever had an injury (sprain, muscle/ligament tear, tendinitis, etc.) that caused you to miss a practice or
game? (If yes, circle affected area in the box below):
*10) Have you had any broken/fractured bones or dislocated joints?


(If yes, circle affected area in the box below):
* 11) Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical
therapy, a brace, a cast, or crutches? (If yes, circle affected area in the box below):
Head
Hand/Fingers

Neck

Shoulder
Chest

Knee

Upper Arm

Upper Back
Calf/Shin

Elbow

Low Back
Ankle

Forearm
Hip

Foot/Toes

NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

Thigh

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

12) Have you ever had a stress fracture?

13) Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?
14) Do you regularly use a brace or assistive device?
15) Has a doctor told you that you have asthma or allergies?
16) Do you cough, wheeze, or have difficulty breathing during or after exercise?
17) Is there anyone in your family who has asthma?
18) Have you ever used an inhaler or taken asthma medicine?
19) Were you born without, are you missing, or do you have a nonfunctioning kidney,
eye, testicle or any other organ?
20) Have you had infectious mononucleosis (mono) within the last month?
21) Do you have any rashes, pressure sores, or other skin problems?
22) Have you had a herpes skin infection?
23) Have you ever had an injury to your face, head, skull or brain (including a concussion, confusion, memory loss
or headache from a hit to your head, having your bell rung or getting dinged)?
24) Have you ever had a seizure?

25) Do you have headaches with exercise?

26) Have you ever had numbness, tingling, or weakness in your arms or legs after being hit, falling, stingers or burners?
27) When exercising in the heat, do you have severe muscle cramps or become ill?
28) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?
29) Have you ever been tested for sickle cell trait?
30) Have you had any problems with your eyes or vision?
31) Do you wear glasses or contact lenses?
32) Do you wear protective eyewear, such as goggles or a face shield?
33) Are you happy with your weight?
34) Are you trying to gain or lose weight?
35) Has anyone recommended you change your weight or eating habits?
36) Do you limit or carefully control what you eat?
37) Do you have any concerns that you would like to discuss with a doctor?

Females Only

Explain Yes Answers Here

Y

38) Have you ever had a menstrual period?

39) How old were you when you had your first
menstrual period?
40) How many periods have you had in the
last year?

NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

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

2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

(The Physician should fill out this form with assistance from the Parent or Guardian.)
Student Name:

Date of Birth:

Patient History Questions: Please tell me about your child...

Y

1) Has your child fainted or passed out DURING or AFTER exercise, emotion or startle?
2) Has your child ever had extreme shortness of breath during exercise?
3) Has your child had extreme fatigue associated with exercise (different from other children)?
4) Has your child ever had discomfort, pain or pressure in his/her chest during exercise?
5) Has a doctor ever ordered a test for your child's heart?
6) Has your child ever been diagnosed with an unexplained seizure disorder?
7) Has your child ever been diagnosed with exercise-induced asthma not well controlled with medication?

Family History Questions: Please tell me about any of the following in your family...

8) Are there any family members who had sudden, unexpected, unexplained death before age 50? (including SIDS, car accidents, drowning, or
near drowning)
9) Are there any family members who died suddenly of "heart problems" before age 50?
10) Are there any family members who have unexplained fainting or seizures?
11) Are there any relatives with certain conditions, such as:

Enlarged Heart

Marfan Syndrome (Aortic Rupture)

Heart Attack, age 50 or younger

Hypertrophic Cardiomyopathy (HCM)

Pacemaker or Implanted Defibrillator

Dilated Cardiomyopathy (DCM)

Deaf at Birth (Congenital Deafness)

Heart Rhythm problems:

Explain Yes Answers Here

Long QT Syndrome (LQTS)

Short QT Syndrome
Brugada Syndrome
Catecholaminergic Polymorphic Ventricular
Tachycardia (CPVT)
Arrhythmogenic Right Ventricular
Cardiomyopathy (ARVC)

I hereby state that, to the best of my knowledge, my answers to all of the

above questions are complete and correct. Furthermore, I acknowledge
and understand that my eligibility may be revoked if I have not given
truthful and accurate information in response to the above questions.

Signature of athlete

Signature of parent/guardian

Signature of MD/DO/
N
N
D/N
MD/ P/PA-C/CCSP

Date

Date:

NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

FORM 15.7-A

02/14

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

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Dobson Road

Ironwood Drive

Bank of
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County Rd.

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N. Arizola Rd.

Walgreens

W. McDowell Rd.

60

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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

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W. Dunlap Ave.

17

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5410 W. Thunderbird Road, Suite #101

9494 W. Northern Ave.

E. McKellips Rd

60

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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

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(99th Ave.)

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Greenfield

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Walmart

Walgreens

Phoenix
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Safeway

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N. 16th St.

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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
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Glendale 85308

8101 N. 19th Avenue, Ste. A

Phoenix, AZ 85021

N. 35th Ave

N. 43rd Ave

N. 51st Ave

N. 59th Ave

Peoria/Glendale
9494
W. Northern Ave., Suite #101

N. Lindsay Rd.

Wheeler
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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

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N. Navajo Dr.

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N. 98th Ave.

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914 N. Scottsdale Rd., Suite #104

Sun City, 85351

TUCSON

Tucson
85712
6238 E. Pima
St.
6238 E. Pima Street
Tucson

Metro
Wildcat

E. 6th St.

Tucson 85719
501 North Park Ave., Suite #110

501 N. Park Ave., Ste. 110

E. Old Span
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Target

S Harrison Rd

Speedway

University Blvd.

Starbucks

N. Park Ave.

Wilmot

10

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Speedway Blvd.

Circle K
10

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69

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Pima

N. Navajo Dr.

W. Miracle Mile
4280 N. Oracle Rd. Ste. 100
Tucson, 85705
AZ 85705

3051 N.Windsong
Prescott Valley
86314 Dr.

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Hampton Inn
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va
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W. Valencia Rd.
E. Florentine Rd.
N. Glassford Hill Rd.

Willow Creek Rd.

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101

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86336
2530 W. SR 89A
2530 W. SR 89A, Suite #A
Sedona, AZ 86336
(Arizona 89A & Andante Dr.)

N. Windsong Dr.

Ca

89A

7425 E. Shea Blvd., Suite #108

N. 99th

Stutz Bearcat Dr.

E. Mountain View Rd

Scottsdale 85260

Blue Heron Way

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101

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Scottsdale Road

Phoenix, AZ 85035

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3229 E. Greenway Rd., Suite #102

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101

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Greenway Rd.

Phoenix
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E. Thunderbird Rd.

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N. 59th Ave.

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W. McDowell Rd.

N. 40th St.

N. 32nd St.

51

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E. D

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W. Coronado Rd.

E. Bell Rd.

9525 E.Old
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