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
?
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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