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 *

Medical

Appearance

Eyes/Ears/Throat/Nose

Hearing

Lymph Nodes

Heart

Murmurs

Pulses

Lungs

Abdomen

Genitourinary &

Skin

Musculoskeletal

Neck

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:_____________________________

Medically eligible for all sports without restriction with recommentations for further evaluation or treatment of:

__________________________________________________________________________________________________________

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 07/07/2022 (rev.) NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.

Visit website for additional locations & hours



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1-888-705-8562 Holiday Inn

San Gabriel

N. 51st Ave N. 59th Ave N. 67th Ave

Thunderbird Pa

Broadway Road

W. Indian School Rd.

Meridian Road Ironwood Drive

N. Dysart Rd. N. Litch eld Rd.

Southern Avenue

Walgreens

60

Apache Junction ? 85120

2080 West Southern Ave., Suite #A1

W. McDowell Rd.

Fry's

W. Van Buren St.

Avondale ? 85392

13075 W. McDowell Rd., Suite #D106

E. Cottonwood Ln.

Bank of

10

America

E. Florence Blvd.

C99asStoare GranWdalmeart? 85122

1683 E. Florence Blvd., Suite #7

Airpark Rd.

N. 99th Ave. N. 91st Ave.

N. Mesa Dr. N. Horne

S. Calvary Way S. Willard St.

89A

89A

W. Cottonwood St.

Cottonwood ? 86326

450 S. Willard Street, Suite #120

W. Olive Ave.

Target 101

W. Northern Ave.

101

W. Glendale Ave.

Glendale ? 85305

9Pe4o9ria4/GWlen.dNaleorthern Ave., Suite #101

9494 W. Northern Ave.

LOOP

202

Walmart

McKellips Dr.

Mesa ? 85203

535 E. McKellips Road, Suite #101

StNr.eeHtumphreys N. Beaver Street

S Malpais Lane Rd

Flagstaff Medical Center

180

Basha's

N. Fort Valley Roa

d 180

W. Desilva Avenue

W. Columbus Avenue

Flagstaff ? 86001

1000 N. Humphreys St., Suite #104

W. Greenway Rd

40

W Clay Ave

Barnes & Noble Dairy Queen

Natural Grocers

S Milton

W Butler Ave

Northern Arizona University

Flagstaff ? 86001

399 S. Malpais Lane, Suite #100

101

N. 59th Ave N. 55th Ave N. 51st Ave N. 43rd Ave N. 35th Ave

H

seo Park

W. Thunderbird Rd

ASU West Campus

Glendale ? 85306

5410 W. Thunderbird Road, Suite #101

17

Honeywell

W. Union Hills Dr

Starbucks

Glendale ? 85308

18589 N. 59th Ave., Suite #101

N. Lindsay Rd. S. 32nd St.

Dana Park

N. Val Vista Dr.

N. Recker Rd N. Power Rd

60

Baseline Road

E. McKellips Rd

202 E. Brown Rd

Red Mountain High School

Mesa ? 85204

3130 E. Baseline Road, Suite #105

Mesa ? 85205

1066 N. Power Road, Suite #101

N. Verbena Henness Rd. County Rd.

N. Arizola Rd.

N. Mastick Way N. Grand Avenue

Lake Pleasant Road

(99th Ave.) (91st Ave.)

Chandler Blvd. Frye Road

Dobson Road

Pecos Road

Chandler ? 85224

600 S. Dobson Road, Suite #C-26

Chase Bank

S. Higley Rd

Chevron

Walgreens

E. Chandler Heights Rd

Gilbert ? 85298

6343 S. Higley Road

Safeway

McDonald's

W. Elliot Rd

Starpointe Resident Club

Goodyear ? 85338

17688 W. Elliot Road

Washington Federal

JcPenney

W. Mariposa Road

Nogales ? 85621

298 W. Mariposa Road

W.

NextCare

Ocotillo

Road

Urgent

Care Coconut's

Fish Caf?

S. Alma School Rd

Ocotillo Village Health Club

Chandler ? 85248

1155 W. Ocotillo Road, Suite #4

W. Cactus Rd. 17

N. 51st Ave. N. 43rd Ave.

Peoria Ave.

17 W. Dunlap Ave.

Gle1n02d4a0 Nleor?th84533rd0A2venue,

102S4t0e N#3. 43rd Ave., Suite #3 Glendale, AZ 85302

Havasu Regional Medical Center

Riviera Blvd

Civic Center Ln Library L

Capri

Ave.

n Wheeler

95

MeNs.qMuitceCulSlowcahnBsolvnd.Ave.

Blvd.

Park

Kmart

Lak

Lake Hav95asu City ? 86403

1810 Mesquitee APlveaes.,anStuPitkewBy

Rose Garden Ln.

Bashas

Walgreens

101

Beardsley Rd.

Peoria ? 85382

20470 N. Lake Pleasant Rd., Suite #102 20470 N. Lake Pleasant Rd. Suite 102

Miller V

E. Osborn Rd.

N. 16th St.

E. Thomas Rd.

51

Phoenix Children's Hospital

N. 21st St.

E. Oak St.

Phoenix ? 85016

1701 E. Thomas Road, Suite #A104

W. Coronado Rd.

W. McDowell Rd.

Walgreens

7-11

N. 59th Ave.

Phoenix ? 85035 59592200WW..McDDoowweelllRRdo, ad Phoenix, AZ 85035

E Oak St

Dairy Queen Bei Sushi Bar

Goodwill

S. Calvary Way S. Willard St.

N. Scottsdale Rd N 71st St

89AE Palm Ln

Scottsdale ? 85257

reet, Suite 2112202 N. Scottsdale Road

Z 86326

Willard Street)

lace Blvd.

WOOD

Starbucks

E

Dave & Busters

.Tucson Marketp

S. Kino Parkway

S. Park Avenue

Willow Creek Rd.

10

Costco

E. Ajo Way

Tucson ? 85713

1570 E. Tucson Marketplace Blvd.

N. 20 th St.

Visit website for additional locations & hours SEDONA

? 1-888-705-8562 89A

Rigby Rd.

S. Candy Ln.

Andante Dr.

S. Willard St.

N. 7th Ave.

N. Arcadia Dr.

N. 40th St.

Safeway

48th St.

N. 44th St.

Indian School

Arcadia H.S.

Phoenix ? 85018

4730 E. Indian School Rd., Suite #211

E. Rose Garden Ln.

E. Deer Valley Rd.

DESERT RIDGE MARKET PLACE

N. 19th Ave.

S. Calvary Way

Albertson's

17

W. Northern A89vAe.

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

PhoCeOnTiTxO?N8W50O2O1D

8101 N. 19th Ave., Suite #A

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

Green Ln.

Greenway Rd.

N. 40th St. N. 32nd St.

Stutz Bearcat Dr.

89A

E. Bell Rd.

51

Food City

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

Blue Heron Way

Arizona Canal Trail 7-Eleven

E. Camelback Rd.

CVS

Sushiholic Arcadia Villa Apartments

E. Elm St.

Phoenix E. Thunderbird ?Rd. 85032

3229 E. Greenway Rd., Suite #102

Phoenix ? 85018

3931 E. Camelback Road

E. LakeshE.orFeloDrern.tine Rd. E. Florentine Dr.

Harkins Theaters E. Shea Blvd

N. Windsong Dr. N. Glassford Hill Rd. N. Windsong Dr.

N. RobertN.RRdo.bert Rd. N. Navajo Dr. N. 70th St

N. Scottsdale Rd N. 74th St

Willow Creek Rd.

N. Tatum Blvd.

Miller Valley Rd.

101 101

Phoenix ? 85050

220095905N0TaNtum. TBalvdtu, SmuiteB19lv0,dPh.,oeSniux,iAteZ 8#501590 0

SED2P(GOP20rer06resN62ece2onWsAtWLticl,nloAoi.llwZ&ottw8WC6?riCe3l8le0orke61we3RCkd0r.1ReeokaRdd.) PRESW.CUnOionTHiTlls Dr.

Rigby Rd.

N. 99th Ave N. 98th Ave. N. 91st Ave.

Andante Dr.

101 89A

W Bell Rd.

Blue Heron Way

Stutz Bearcat Dr.

Sed25o3n0aW?.8S6R38396A 253S0eWd.oSnRa,8A9AZ,8S6u3it3e6#A

(Arizona 89A & Andante Dr.)

101

W. Thunderbird Rd.

Sun City ? 85351

97947545WW. B. BeelllRl Rooaadd,,SSuuiittee #110505

Sun City, 85351

S. Midvale Park Rd. S. Calle Santa Cruz Rd.

N. Flowing Wells Rd. N. Oracle Rd.

77 W. Wetmore Rd.

10

W. Limberlast Dr.

Walgreens

W. Prince Rd. E. Florentine Rd.

W. Miracle Mile

4280 N. Oracle Rd. Ste. 100

TucsoTnucso?n, 8AZ585770055

4280 North Oracle Rd., Suite #100

N. Navajo Dr.

N. Windsong Dr. N. Robert Rd.

N. Glassford Hill Rd.

69

86

W. Ajo Way W. Irvington Rd.

W. Drexel Rd. W. Valencia Rd.

86 19 10

Harkins

Tucson ? 85706

55336699 SS.. CCaallleleSSanatnatCarCuzr,uSzuite #145 Suite 145, Tucson, 85706

69 E. Mountain View Rd

69

Prescott Va3l0l5e1yN.?W8i6nd3s1o4ng Dr.

Scottsdale ? 85260

3051

N.

WindsP(Eor.enFsglcooDrtertniVvteianlleeyR,dA&Z

86314 Windsong

Dr.7)425

E.

Shea

Blvd.,

Suite

#108

PRESCOTT W.GrandAve VALLEY Banner Del

E. Webb

Hampton Inn

60

Medical

303 W. Mountain View Blvd

& Suites Colon n de

a Way

Center

Albertson's

Market

Curry Road

Jack in the Box

LOOP

202

Rural Scottsdale Road

N. Reems Rd

W. Bell Rd

Surprise ? 85374

14800 W. Mtn. View Blvd., Suite #100

Circle K Pima

10

Speedway

Wilmot

N. Euclid Ave. N. Park Ave.

Tempe ? 85281

914 N. Scottsdale Rd., Suite #104

TUCSON

Speedway Blvd.

10

University Blvd.

Metro Wildcat

E. 6th St.

T6u2c3s8oEn. P? i8m5a71S2t. 6T23u8csEo. nPima Street

Tucson ? 85719

501 North Park Ave., Suite #110

501 N. Park Ave., Ste. 110

N. Hayden Rd

S Harrison Rd S. Avenue B

E. Main Canal Road S. 14th Avenue

S. Avenue A S. 4th Avenue

E. Old Spanish Trail

Starbucks Target

W. 8th Street

E 22nd St

Tu9c5s2o5nE.?O8l5d7S4p8anish Trail 952T5uEcs. oOnld Spanish Trail, Suite #101

95

W. 16th Street

Yuma ? 85364

1394 W. 16th Street

Visit website for additional locations & hours

? 1-888-705-8562

8

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