ARIZONA INTERSCHOLASTIC ASSOCIATION7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Health Care Partner of the Arizona Interscholastic Association
2019-20 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION(The parent or guardian should fill out this form with assistance from the student-athlete) Exam Date: _________________
Name: __________________________________________________________
Home Address: ___________________________________________________
Phone: __________________________________________________________
Date of Birth: ____________________________________________________
Age: ____________________________________________________________
Gender: _________________________________________________________
Grade: __________________________________________________________
School: __________________________________________________________
Sport(s): _________________________________________________________
Personal Physician: _______________________________________________
Hospital Preference: ______________________________________________
In case of emergency contact:
Name: ______________________________
Relationship: _________________________
Phone (Home): _______________________
Phone (Work): ________________________
Phone (Cell): _________________________
Name: ______________________________
Relationship: _________________________
Phone (Home): _______________________
Phone (Work): ________________________
Phone (Cell): _________________________ Explain “Yes” answers on the following page. Circle questions you don’t know the answers to.
Y N
1) Has a doctor ever denied or restricted your participation in sports for any reason?
2) Do you have an ongoing medical conditional (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 stringing 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 a 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, check affected area in the box below in question 11)
10) Have you had any broken/fractured bones or dislocated joints?
(If yes, check affected area in the box below in question 11):
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, check affected area in the box below):
Head Neck Shoulder Upper Arm Elbow Forearm
Hand/Fingers Chest Upper Back Lower Back Hip Thigh
Knee Calf/Shin Ankle Foot/Toes
FORM 15.7-A 07/01/2018 NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs. 1
ARIZONA INTERSCHOLASTIC ASSOCIATION7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Health Care Partner of the Arizona Interscholastic Association
FORM 15.7-A 07/01/2018 NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs. 2
Y N
12) Have you ever had a stress fracture?
13) Have you ever 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 medication?
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) Have you ever had numbness, tingling or weakness in your arms or legs after being hit, falling, stingers or burners?
26) While exercising in the heat, do you have severe muscle cramps or become ill?
27) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?
28) Have you ever been tested for sickle cell trait?
29) Have you had any problems with your eyes or vision?
30) Do you wear glasses or contact lenses?
31) Do you wear protective eyewear, such as goggles or a face shield?
32) Are you happy with your weight?
33) Are you trying to gain or lose weight?
34) Has anyone recommended you change your weight or eating habits?
35) Do you limit or carefully control what you eat?
36) Do you have any concerns that you would like to discuss with a doctor?
Y N
37) Have you ever had a menstrual period?
38) How old were you when you had your first menstrual period? _______
39) How many periods have you had in the last year? _______
Females Only Explain “Yes” Answers Here
ARIZONA INTERSCHOLASTIC ASSOCIATION7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Health Care Partner of the Arizona Interscholastic Association
FORM 15.7-A 07/01/2018 NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs. 3
2019-20 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATIONThe 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 N1) 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...
Y N8) Are there any family members who had sudden/unexpected/unexplained death before age 50? (including SIDS, car accidents
drowing 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:
Y N Y N Enlarged Heart Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Hypertrophic Cardiomyopathy (HCM) Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
Dilated Cardiomyopathy (DCM) Marfan Syndrome (Aortic Rupture)
Heart Rhythm Problems Heart Attack, Age 50 or Younger
Long QT Syndrome (LQTS) Pacemaker or Implanted Defibrillator
Short QT Syndrome Deaf at Birth
Brugada Syndrome
Explain “Yes” Answers Here
I hereby state that, to the best of my knowledge, my answers to all of the above questions are complete and correct. Further-more, 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 Date
______________________________________________ _______________________Signature of MD/DO/ND/NMD/NP/PA-C/CCSP Date
Ap
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ho
urs
Tem
pe
• 85
281
914
N. S
cotts
dale
Rd.
, Sui
te #
104
Curr
y Ro
ad
Scottsdale Road
LOO
P20
2Jack
inth
e Bo
x
Rural
Tucs
on
• 8
5748
9525
E. O
ld S
pani
sh T
rail,
Sui
te #
101
Yum
a •
8536
413
94 W
. 16t
h S
treet
E. O
ld Sp
anish
Trail
E 22
nd S
t
S Harrison Rd
9525
E. O
ld S
pani
sh T
rail
Tu
cson
Targ
et
Sta
rbuc
ksW
. 8th
Str
eet
S. Avenue B
S. Avenue A
95
E. Main Canal Road
S. 14th Avenue
W. 1
6th
Stre
et
8S. 4th AvenueNE
XT
CA
RE
.CO
M •
1-8
88-7
05-8
562
Vis
it w
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te f
or
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