Arcadia High School Certified Athletic Trainer: Ann Stevens MS, AT Cell:

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1 2018 SUSD Sports Physicals Provided by AZ Sports medicine ProSports Performance and Rehab 0% of the Proceeds go Directly to our Athletic Training Room Every athlete planning on participating in AIA athletics during the school year is required to have a Pre-participation Physical Examination dated after March 1st, The SUSD sports medicine team provides the PPE s at a reduced cost to the athletes of the Scottsdale Unified School District. The physical exam will be given by the Certified Athletic Trainers, Physical Therapists, and Licensed Physicians associated with the sports medicine team that provides care for SUSD athletes throughout the school year. This exam is a comprehensive orthopedic and general medical evaluation. We provide two dates for your convenience. Dates: April 14, AM - OO Location: and/or May 12, AM - OO ProSports Performance and Rehab 8630 E. Via De Ventura Blvd., # Scottsdale, AZ Cost: $20 Cash or check made out to SUSD. Sorry, no credit cards or bills larger than $20. ou must have an appointment to be seen. o walk-ins. To schedule an appointment contact your school s Certified Athletic Trainer (Ann Stevens). Please come dressed in a t-shirt and athletic shorts, and with the medical history portion of the AIA Pre-participation Physical Examination form completed. See your Certified Athletic Trainer or your school s athletic office for an Athletic Packet. Arcadia High School Certified Athletic Trainer: Ann Stevens MS, AT Cell: astevens@susd.org

2 ARIZOA ITERSCHOLASTIC ASSOCIATIO 7007 orth 18th Stree t, Phoenix, Arizona Phone: (602) The Preferred Urgent Care of the Arizona Interscholastic Association AUAL PREPARTICIPATIO PHSICAL EVALUATIO (The Parent or Guardian should fill out this form with assistance from the student athlete.) Exam Date: ame: Home Address: Phone: Date of Birth: Age: Sex: Grade: School: Sport(s): Personal Physician: Hospital Preference: Explain "es" answers on following page. Circle questions you don t know the answers to. In case of emergency, contact: ame: Relationship: Phone (Home): (Work): (Cell): ame: Relationship: Phone (Home): (Work): (Cell): 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): *) 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): eck Shoulder Upper Arm Elbow Forearm Hand/Fingers Chest Upper Back Low Back Hip Thigh 1 Knee Calf/Shin Ankle Foot/Toes extcare is the preferred partner of the AIA, it is not required you visit extcare locations for your healthcare needs.

3 ARIZOA ITERSCHOLASTIC ASSOCIATIO 7007 orth 18th Street, Phoenix, Arizona Phone: (602) ) 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 es Answers Here 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

4 ARIZOA ITERSCHOLASTIC ASSOCIATIO 7007 orth 18th Stree t, Phoenix, Arizona Phone: (602) The Preferred Urgent Care of the Arizona Interscholastic Association AUAL PREPARTICIPATIO PHSICAL EVALUATIO (The Physician should fill out this form with assistance from the Parent or Guardian.) Student ame: Date of Birth: Patient History Questions: Please tell me about your child... 1) Has your child fainted or passed out DURIG 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? ) Are there any family members who have unexplained fainting or seizures? 11) Are there any relatives with certain conditions, such as: Marfan Syndrome (Aortic Rupture) Enlarged Heart Heart Attack, age 50 or younger Hypertrophic Cardiomyopathy (HCM) Dilated Cardiomyopathy (DCM) Pacemaker or Implanted Defibrillator Deaf at Birth (Congenital Deafness) Heart Rhythm problems: Long QT Syndrome (LQTS) Explain es Answers Here 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 Date Signature of MD/DO/D/MD/P/PA-C/CCSP Date: 3 extcare is the preferred partner of the AIA, it is not required you visit extcare locations for your healthcare needs. FORM 15.7-A 02/14

5 7007 orth 18th Street, Phoenix, Arizona Phone: (602) ame: Age: Height: % Body fat (optional): Vision: R20/ L20/ Pupils: Equal Unequal Date of Birth: Sex: Weight: Pulse: BP: / ( /, / ) Corrected: Appearance Eyes/Ears/Throat/ose Hearing Lymph odes Heart Murmurs Pulses Lungs Abdomen Genitourinary Skin eck Back Shoulder/Arm Elbow/Forearm Wrist/Hand/Fingers Hip/Thigh Knee Leg/Ankle Foot/Toes OTES: ormal Abnormal Findings Initials* * Multi-examiner set-up only. Having a third party present is recommended for the genitourinary examination. Cleared Without Restriction ot Cleared For: All Sports Certain Sports Reason: Recommendations: ame of Physician(Print/Type): Address: Signature of Physician: Exam Date: Phone:, MD/DO/P/PA-C

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7 Andante Dr. Stutz Bearcat Dr. The Preferred Health Care Partner of the Arizona Interscholastic Association extcareaz.com. 32nd St. Greenway Rd. E. Bell Rd. Food City th St. W. Coronado Rd. W. McDowell Rd th Ave. E. Rose Garden Ln.. Tatum Blvd. E. Deer Valley Rd. DESERT RIDGE MARKET PLACE Green Ln. Willow Creek Rd. Miller Valley Rd.. Windsong Dr. E. Lakeshore Dr. E. Florentine Dr. 69. Robert Rd. Phoenix E. Greenway Rd., Suite #2 Phoenix W. McDowell Road Phoenix Tatum Blvd., Suite #190 Prescott Willow Creek Road Prescott Valley Windsong Drive Harkins Theaters Rd. W. Union Hills Dr. W. Mountain View Boulevard Hampton Inn & Suites 60 W. Grand Ave. 70th St. Scottsdale Rd. 74th St E. Shea Blvd E. Mountain View Rd. Hayden Rd 89A Blue Heron Way Rigby. 99th Ave. 98th Ave.. 91st Ave. W Bell Rd. W. Thunderbird Rd. Colon n ade Way. Reems Albertson s Market Road Scottsdale Road Rural Curry Road LOOP Jack in the Box Scottsdale E. Shea Blvd., Suite #8 Sedona W. SR 89A, Suite #A Sun City W. Bell Road, Suite #5 Surprise W. Mtn. View Blvd., Suite #0 Tempe Scottsdale Rd., Suite #4. Flowing Wells Rd. W. Wetmore Rd.. Oracle Rd. 77 W. Prince Rd. W. Miracle Mile W. Limberlast Dr W. Ajo Way W. Irvington Rd. W. Drexel Rd. W. Valencia Rd. S. Midvale Park Rd. S. Calle Santa Cruz Rd. 19 Harkins Pima Wilmot Circle K Speedway Speedway Blvd.. Euclid Ave. E. 6th St. University Blvd. Metro Wildcat. Park Ave. E. Old Spanish Trail E 22nd St S Harrison Rd Starbucks Target Oracle Rd. Ste. 0 Tucson orth Oracle Rd., Suite #0 Tucson S. Calle Santa Cruz, Suite #145 Tucson E. Pima Street Tucson orth Park Ave., Suite #1 Tucson E. Old Spanish Trail, Suite #