ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Street, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

2016-2017 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION

The Preferred Health Care Partner of the Arizona Interscholastic Association

Name: Sex: Age: Date of Birth:

Height: Weight:% Body fat (optional):

Pupils:

Pulse:

BP:____/____ (____ /____,____/____)

Corrected: Y___ N___Vision: R20/_____ L20/_____

Normal Abnormal Findings Initials*

Medical

Musculoskeletal

Appearance

Lymph Nodes

Back

Pulses

Wrist/Hand/Fingers

Eyes/Ears/ Throat/Nose

Heart

Shoulder/Arm

Lungs

Hip/Thigh

Genitourinary †

Leg/Ankle

Hearing

Neck

Murmurs

Elbow/Forearm

Abdomen

Knee

Skin

Foot/Toes* Multi-examiner set-up only.† Having a third party present is recommended for the genitourinary examination.

NOTES:

Recommendations:

Name of Physician(Print/Type):

Address:

Signature of Physician:

FORM 15.7-B 03/12

Exam Date:

Phone:

, MD/DO/ND/NMD/NP/PA-C/CCSP

Cleared Without RestrictionNot Cleared For: All Sports Certain Sports Reason:

Equal_____ Unequal____

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

1-888-364-7502NextCareAZ.com

Apache Junction • 851202080 West Southern Ave., Suite #A1

Broadway Road

Mer

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n Ro

ad

Ironw

ood

Driv

e

Southern Avenue

60

Walgreens

Avondale • 8539213075 W. McDowell Rd., Suite #D106

W. McDowell Rd.

W. Van Buren St.

W. Indian School Rd.

N. D

ysart Rd.

N. Litch�eld Rd.

Fry’s

Casa Grande • 851221683 E. Florence Blvd., Suite #7

10

E. Florence Blvd.

E. Cottonwood Ln.

N. A

rizola Rd.

County Rd.

N. Verbena H

enness Rd.

99¢ Store

Bank ofAmerica

Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26

Pecos Road Dob

son

Roa

dFrye Road

Chandler Blvd.

Glendale • 853065410 W. Thunderbird Road, Suite #101

W. Greenway Rd

N. 5

9th

Ave

N. 5

1st A

ve

N. 4

3rd

Ave

W. Thunderbird RdASU West Campus

Thunderbird Paseo Park

N. 3

5th

Ave

17N. 5

5th

Ave

H

Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302

W. Cactus Rd.

Peoria Ave.

N. 5

1st A

ve.

N. 4

3rd

Ave.

W. Dunlap Ave.

17

17

Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.

W. Olive Ave.

W. Northern Ave.N. 9

9th

Ave.

N. 9

1st A

ve.

W. Glendale Ave.

101

101

Target

Mesa • 852051066 N. Power Road, Suite #101

E. Brown Rd

Red MountainHigh School

N. P

ower

Rd

202

N. R

ecke

r Rd

E. McKellips Rd

Mesa • 852043130 E. Baseline Road, Suite #105

60

Baseline Road

N. L

inds

ay R

d.

N. V

al V

ista

Dr.

S. 3

2nd

St.

Dan

a Pa

rk

Mesa • 85203535 E. McKellips Road, Suite #101

McKellips Dr.

N. M

esa

Dr.

N. H

orne

LOOP202

Walmart

Cottonwood • 86326450 S. Willard Street, Suite #120

89AS. Calv

ary W

ayS.

Willa

rd St

.

W. Cottonwood St.

Airpark Rd.

89A

Glendale • 8530818589 N. 59th Ave., Suite #101

N. 59th Ave

W. Union Hills Dr

Honeywell

101

N. 51st Ave

N. 67th Ave

Starbucks

Chino Valley • 86323474 State Highway 89

Safeway

89

89

W. Rd 1 N E. Rd 1 N

W. Rd 2 N

N. R

d 1

E

Walgreens

Center St.

Chino ValleyHigh School

Flagstaff • 860011000 N. Humphreys St., Suite #104

180

180

N. F ort Valley Road

N. H

umph

reys

St

reet

W. Columbus Avenue

W. Desilva Avenue

Basha’sN

. Bea

ver S

tree

t

Flagstaff MedicalCenter

Lake Havasu City • 864031810 Mesquite Ave., Suite B

Kmart95 Mesqu

ite A

ve.

N. McC

ulloch

Blvd.

Rivi

era

Blv

d

Capri Blvd.Library Ln

Civic Center Ln

95

Swanso

n Ave.

WheelerPark

Havasu RegionalMedical Center

Mesa • 852154401 E. McKellips Road, Suite #102

LOOP202

McKellipsVal V

ista

Gre

en�e

ld

McDowell

Walmart

Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102

Rose Garden Ln.

Beardsley Rd.

Lake

Ple

asan

t Roa

d(9

9th

Ave.

)

(91s

t Av

e.)

101

20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382

LakePleasant Pkwy

Bashas

Walgreens

Phoenix • 850161701 E. Thomas Road, Suite #A104

51

E. Oak St.

E. Thomas Rd.

E. Osborn Rd.

N. 16th St.

N. 21st St.

N. 20 th St.

PhoenixChildren’sHospital

Phoenix • 850184730 E. Indian School Rd., Suite #211

N. A

rcad

ia Dr.

Indian School

N. 4

4th

St.

48th

St.

Arcadia H.S.

Safeway

Phoenix • 850218101 N. 19th Ave., Suite #A

8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021

W. Northern Ave.

W. Orangewood Ave.N. 1

9th

Ave.

N. 7

th A

ve.

17

Albertson’s

The Preferred Health Care Partner of the Arizona Interscholastic Association

Phoenix • 8505020950 N. Tatum Blvd., Suite #19020950 N Tatum Blvd, Suite 190, Phoenix, AZ 85050

E. Deer Valley Rd.

N. T

atum

Blv

d.

E. Rose Garden Ln.DESERT RIDGEMARKET PLACE

101101

Scottsdale • 852607425 E. Shea Blvd., Suite #108

N. S

cott

sdal

e Rd

E. Shea Blvd

Harkins Theaters

N. H

ayden Rd

E. Mountain View Rd

N. 7

0th

St

101

N. 7

4th

St

Sun City • 853519745 W. Bell Road, Suite #1059745 W. Bell Road, Suite 105

Sun City, 85351

W. Union Hills Dr.

W Bell Rd.N. 9

9th

Ave

N. 9

8th

Ave

.

N. 9

1st

Ave.

W. Thunderbird Rd.

101

101

Tempe • 85281914 N. Scottsdale Rd., Suite #104

Curry Road

Scot

tsda

le R

oad

LOOP202

Jack inthe Box

Rura

l

Tucson • 857126238 E. Pima Street

Pima

SpeedwayW

ilmot10

6238 E. Pima St. Tucson

Circle K

Tucson • 857489525 E. Old Spanish Trail, Suite #101

E. Old Spanish Trail

E 22nd St

S Ha

rriso

n Rd

9525 E. Old Spanish Trail Tucson

Target

Starbucks

Tucson • 857054280 North Oracle Rd., Suite #100

W. Wetmore Rd.

W. Prince Rd.

W. Miracle Mile

N. O

racl

e Rd

.

N. F

low

ing

Wel

ls R

d.

10

4280 N. Oracle Rd. Ste. 100Tucson, AZ 85705

77

Walgreens

W. Limberlast Dr.

Tucson • 857065369 S. Calle Santa Cruz, Suite #145

W. Ajo Way

W. Valencia Rd.

W. Drexel Rd.

W. Irvington Rd.

S. M

idva

le P

ark

Rd.

S. C

alle

San

ta C

ruz R

d.

10

86 86

5369 S. Calle Santa Cruz Suite 145, Tucson, 85706

Harkins

19

Tucson • 85719501 North Park Ave., Suite #110

E. 6th St.

Speedway Blvd.

University Blvd.

N. E

uclid

Ave

.

10

N.P

ark

Ave.

TUCSON

501 N. Park Ave., Ste. 110

MetroWildcat

Sedona • 863362530 W. SR 89A, Suite #A

89A

yaW nor e

H eul B

.rD t acr aeB zt ut S

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Anda

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Dr.

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C. S

S. C

alvar

y Way

COTTONWOOD

PRESCOTT PRESCOTT VALLEY

89A

89A

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

N. G

lass

ford

Hill

Rd.

N. N

avaj

o D

r.

N. R

ober

t Rd.

N. W

inds

ong

Dr.

450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)

2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)

2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)

3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)

69

E. Florentine Rd.

Prescott • 863012062 Willow Creek Road

89A

yaW

noreH

eul B

.rDt acr aeB

zt ut S

. d Rybgi R

Anda

nte

Dr.

SEDONA

.t Sdr alli

W. S

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C. S

S. C

alvar

y Way

COTTONWOOD

PRESCOTT PRESCOTT VALLEY

89A

89A

Green Ln.

Miller Valley Rd.

Willow

Creek R

d.

N. G

lass

ford

Hill

Rd.

N. N

avaj

o D

r.

N. R

ober

t Rd.

N. W

inds

ong

Dr.

450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)

2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)

2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)

3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)

69

E. Florentine Rd.

Prescott Valley • 863143051 N. Windsong Drive

N. W

inds

ong

Dr.

N. R

ober

t Rd.

69

E. Florentine Dr.

E. Lakeshore Dr.

Phoenix • 850323229 E. Greenway Rd., Suite #102

51

E. Thunderbird Rd.

Greenway Rd.

E. Bell Rd.

N. 32nd St.

N. 40th St.

Food City

Phoenix • 850355920 W. McDowell Road

W. McDowell Rd.

W. Coronado Rd.

N. 59th Ave.

5920 W. McDowell Rd, Phoenix, AZ 85035

7-11

Walgreens

Surprise • 8537414800 W. Mtn. View Blvd., Suite #100

60

N. Reem

s Road

W. Mountain View Boulevard

Hampton Inn & Suites

Albertson’sMarket

W. Grand Ave

Colon n ade Way

1-888-364-7502NextCareAZ.com

The Preferred Health Care Partner of the Arizona Interscholastic Association