The Preferred Urgent Care of the Arizona Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION 7007 North 18th Street, Phoenix, Arizona 85020-5552 Phone: (602) 385-3810
2017-2018 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 don’t 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
1
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
N
The Preferred Urgent Care of the Arizona Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION 7007 North 18th Street, Phoenix, Arizona 85020-5552 Phone: (602) 385-3810
Y
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
N
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?
2
NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.
N
The Preferred Urgent Care of the Arizona Interscholastic Association
ARIZONA INTERSCHOLASTIC ASSOCIATION 7007 North 18th Street, Phoenix, Arizona 85020-5552 Phone: (602) 385-3810
2017-2018 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
N
Y
N
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:
Y
N
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
3
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
W. Rd 2 N
Chandler Blvd. Dobson Road
Ironwood Drive
Bank of America
County Rd.
Fry’s
N. Arizola Rd.
Walgreens
W. McDowell Rd.
60
E. Cottonwood Ln.
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
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W. Dunlap Ave.
17
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Flagstaff • 86001
Glendale • 85302
450 S. Willard Street, Suite #120
1000 N. Humphreys St., Suite #104
10240 N. 43rd Ave., Suite #3
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9494 W. Northern Ave.
E. McKellips Rd
60
Baseline Road
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
Beardsley Rd.
E. Oak St.
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W. Northern Ave.
Indian School
Arcadia H.S.
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E. Thomas Rd. 101
51
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(91st Ave.)
(99th Ave.)
Lake Pleasant Road
Greenfield
Val Vista
Walmart
Walgreens
Phoenix Children’s Hospital
Safeway
N. 21st St.
McKellips
Bashas
N. 16th St.
McDowell
E. Osborn Rd.
N. A rca d
N. 20 th St.
Rose Garden Ln. LOOP
202
N. 44th St.
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W. Orangewood Ave.
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 La
Glendale • 85308
8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021
N. 35th Ave
N. 43rd Ave
N. 51st Ave
N. 59th Ave
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Peoria/Glendale 9494 W. Northern Ave., Suite #101
N. Lindsay Rd.
Wheeler Park
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202
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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. 91st Ave.
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Surprise • 85374
Tempe • 85281
14800 W. Mtn. View Blvd., Suite #100
914 N. Scottsdale Rd., Suite #104
Sun City, 85351
TUCSON
Speedway Blvd.
Tucson • 85712 6238 E. Pima St. 6238 E. Pima Street Tucson
Speedway
Metro Wildcat
E. 6th St.
Tucson • 85719 501 North Park Ave., Suite #110
501 N. Park Ave., Ste. 110
E. Old Span ish T rail E 22nd St
Target
S Harrison Rd
10
University Blvd.
Starbucks
N. Park Ave.
Circle K 10
Harkins
69
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Pima
N. Navajo Dr.
W. Miracle Mile 4280 N. Oracle Rd. Ste. 100 Tucson, 85705 AZ 85705
(E. Florentine Rd & Windsong Dr.)
Sun City • 85351
10
W. Valencia Rd. E. Florentine Rd. N. Glassford Hill Rd.
Willow Creek Rd.
W. Drexel Rd.
60
W Bell Rd.
N. Euclid Ave.
Walgreens
Prescott Valley, AZ 86314 3051 N. Windsong Drive
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101
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77
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10
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Sedona • 86336 2530 W. SR 89A 2530 W. SR 89A, Suite #A Sedona, AZ 86336 (Arizona 89A & Andante Dr.)
N. Robert Rd.
WOOD
N. Oracle Rd.
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N. Flowing Wells Rd.
7425 E. Shea Blvd., Suite #108
N. Windsong Dr.
Ca
89A
N. 98th Ave.
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Stutz Bearcat Dr.
E. Mountain View Rd
Scottsdale • 85260
Blue Heron Way
89A 101
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N. Scottsdale Rd
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2062 Willow Creek Rd. Prescott • 86301 Prescott, AZ 86301 2062 Willow Creek Road (Green Ln. & Willow Creek Rd.)
Scottsdale Road
Phoenix, AZ 85035
Harkins Theaters
. Rd
20950 N. Tatum Blvd., Suite #190
69
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E. Florentine Dr.
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Phoenix • 85035
3229 E. Greenway Rd., Suite #102
E. Lakeshore Dr. E. Florentine Rd.
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101
Green Ln.
N. Tatum Blvd.
7-11
Greenway Rd.
Phoenix • 85032 E. Thunderbird Rd.
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DESERT RIDGE MARKET PLACE
E. Rose Garden Ln.
N. 59th Ave.
Food City
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Walgreens
W. McDowell Rd.
N. 40th St.
N. 32nd St.
51
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N. Glassford Hill Rd.
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N. Windsong Dr.
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Willow Creek Rd.
W. Coronado Rd.
E. Bell Rd.
9525 E.•Old Spanish Trail Tucson 85748 9525 E. Old Spanish Trail, Suite #101 Tucson
