Head Neck Shoulder Upper Arm Elbow Forearm. Hand/Fingers Chest Upper Back Low Back Hip Thigh. Knee Calf/Shin Ankle Foot/Toes
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1 ARIZOA ITERSCHOLASTIC ASSOCIATIO 00 orth 8th Street, Phoenix, Arizona Phone: (60) AUAL PREPARTICIPATIO PHSICAL EVALUATIO (The Parent or Guardian should fill out this form with assistance from the student athlete.) Exam Date: ame: Sex: Age: Grade: School: Sport(s): Address: Phone: 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): ) Has a doctor ever denied or restricted your participation in sports for any reason? ) 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 ) 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): * ) 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 eck Shoulder Upper Arm Elbow Forearm Hand/Fingers Chest Upper Back Low Back Hip Thigh 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.
2 ARIZOA ITERSCHOLASTIC ASSOCIATIO 00 orth 8th Street, Phoenix, Arizona Phone: (60) ) Have you ever had a stress fracture? 3) Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability? 4) Do you regularly use a brace or assistive device? 5) Has a doctor told you that you have asthma or allergies? 6) Do you cough, wheeze, or have difficulty breathing during or after exercise? ) Is there anyone in your family who has asthma? 8) Have you ever used an inhaler or taken asthma medicine? 9) Were you born without, are you missing, or do you have a nonfunctioning kidney, eye, testicle or any other organ? 0) Have you had infectious mononucleosis (mono) within the last month? ) Do you have any rashes, pressure sores, or other skin problems? ) Have you had a herpes skin infection? 3) 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 )? 4) Have you ever had a seizure? 5) Do you have headaches with exercise? 6) Have you ever had numbness, tingling, or weakness in your arms or legs after being hit, falling, stingers or burners? ) When exercising in the heat, do you have severe muscle cramps or become ill? 8) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? 9) Have you ever been tested for sickle cell trait? 30) Have you had any problems with your eyes or vision? 3) Do you wear glasses or contact lenses? 3) 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? 3) 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? extcare is the preferred partner of the AIA, it is not required you visit extcare locations for your healthcare needs.
3 ARIZOA ITERSCHOLASTIC ASSOCIATIO 00 orth 8th Street, Phoenix, Arizona Phone: (60) AUAL PREPARTICIPATIO PHSICAL EVALUATIO (The Physician should fill out this form with assistance from the Parent or Guardian.) Student ame: Patient History Questions: Please tell me about your child... ) Has your child fainted or passed out DURIG or AFTER exercise, emotion or startle? ) 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? ) 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? ) 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 5.-A 0/4
4 ARIZOA ITERSCHOLASTIC ASSOCIATIO 00 orth 8th Street, Phoenix, Arizona Phone: (60) AUAL PREPARTICIPATIO PHSICAL EXAMIATIO ame: Age: Height: % Body fat (optional): Vision: R0/ L0/ Pupils: Equal Unequal Sex: Weight: Pulse: BP: / ( /, / ) Corrected: Medical Appearance Eyes/Ears/ Throat/ose Hearing Lymph odes Heart Murmurs Pulses Lungs Abdomen Genitourinary Skin Musculoskeletal 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/D/MD/P/PA-C/CCSP FORM 5.-B 03/ extcare is the preferred partner of the AIA, it is not required you visit extcare locations for your healthcare needs.
5 . Glassford Hill Rd. Andante Dr.. Windsong Dr. S. Willard St. S. Candy Ln. Stutz. Robert Rd. Blue Bearcat Heron Dr. Way. avajo Dr Open Day A Week; Extended Hours extcareaz.com APACHE JUCTIO 080 W. Southern Ave., Ste. A, AZ 850 (Southern Ave. & S. Ironwood Dr.) AVODALE 305 W. McDowell Rd., Ste. D6, AZ 8539 (McDowell Rd. & Dysart Rd.) CASA GRADE 683 E. Florence Blvd., Ste., AZ 85 (Florence Blvd. &. Arizola Rd.) CHADLER 600 S. Dobson Rd., Ste. C-6, AZ 854 OPE 8AM-MIDIGHT, DAS A WEEK! (Dobson Rd. & W. Frye Rd.) GLEDALE th Ave., Ste., AZ (. 59th Ave. & W. Union Hills Dr.) rd Ave., Ste. 3, AZ 8530 (W. Peoria Ave. &. 43rd Ave.) 9494 W. orthern Ave., Ste., AZ OPE 8AM-MIDIGHT, DAS A WEEK! (orthern Ave. just E of ) MESA 66. Power Rd., Ste., AZ 8505 (. Power Rd. & E. Brown Rd.) 440 E. McKellips Rd., Ste., AZ 855 (E. McKellips Rd. & Greenfield Rd.) 330 E. Baseline Rd., Ste. 5, AZ 8504 (E. Baseline Rd. West of Val Vista Dr.) 535 E. McKellips Rd., Ste., AZ 8503 (. Mesa Dr. & E. McKellips Rd.) PEORIA 040. Lake Pleasant Rd., Ste., AZ 8538 (. Lake Pleasant Rd. & W. Beardsley Rd.) PHOEIX 39 E. Greenway Rd., Ste., AZ 8503 (E. Greenway Rd. & 3nd St.) 590 W. McDowell Rd., AZ (59th Ave. & W. McDowell Rd.) 0 E. Thomas Rd., Ste. A-4, AZ 8506 OPE 8AM-MIDIGHT, DAS A WEEK! (E. Thomas Rd. & 6th St.) 430 E. Indian School Rd., Ste., AZ 8508 (orth 48th St. & E. Indian School Rd.) 8. 9th Ave., Ste. A, AZ 850 (. 9th Ave. & E. orthern Ave.) SCOTTSDALE 45 E. Shea Blvd., Ste. 8, AZ 8560 (E. Shea Blvd. & 4th St.) 0950.Tatum Blvd., Ste. 90, AZ (On Tatum Blvd. just north of the ) SU CIT 945 W. Bell Rd., Ste. 5, AZ 8535 (. 98th Ave. & W. Bell Rd.) TEMPE 94. Scottsdale Rd., Ste. 4, AZ 858 (. Scottsdale Rd. & E. Curry Rd.) Reems 303 TUCSO 638 E. Pima Street, AZ 85 (Pima Rd. & Wilmot Rd.) 955 E. Old Spanish Trail, Ste., AZ 8548 OPE 8AM-MIDIGHT, DAS A WEEK! (S. Harrison Rd. & Old Spanish Trail Rd.) 480 orth Oracle Rd., Ste. 0, AZ 8505 (Oracle Rd. & Wetmore Rd.) 5369 S. Calle Santa Cruz, Ste. 45, AZ 8506 OPE 8AM-MIDIGHT, DAS A WEEK! (Between W. Irvington Rd. & Drexel Rd. on Calle Santa Cruz) 50 orth Park Ave., Ste., AZ 859 (Park Ave. & 6th St.) COTTOWOOD 450 S. Willard Street, Ste. 0, AZ 8636 (Arizona at Willard Street) SEDOA 530 W. SR, Ste. A, AZ (Arizona & Andante Dr.) PRESCOTT 06 Willow Creek Rd., AZ 8630 (Green Ln. & Willow Creek Rd.) PRESCOTT VALLE 305. Windsong Dr., AZ 8634 (SR 69 & Windsong Dr.) W. Ajo Way Grand Ave. Bell Rd. Dysart Rd. 86 W. Irvington Rd. orth S. Calle Santa Cruz Rd. S. Mission Rd. W. Valencia Rd. Pleasant Lake 99th Ave. McDowell Rd. 0. Flowing Wells Rd.. Oracle Rd. Carefree Beardsley Rd. TUCSO W. Wetmore Rd. 4 W. Limberlost Dr. E. Prince Rd. W. Miracle Mile 9 5 Union Hills 59th Ave. 4 Hwy 5 6 Speedway Broadway E. 6th St. 86 Thomas Rd. Cave Creek Rd. 9th Ave.. Euclid Ave Park Ave.. Campbell Ave. Bell Rd. Greenway Rd. Shea Blvd. orthern Tatum Blvd. 6 Scottsdale 0 E. Grant Rd. Pima 8 Wilmot 0 Dobson Alma School 4 orth Arizona McQueen E. Tanque Verde Rd. Speedway Broadway PHOEIX Countr y Club nd.kolb Rd. Gilbert Greenfield Southern 60 Chandler Blvd. 0 S. Harrison Rd. E. Old Spanish Trail Higley E.Ocotillo Rd. E.Chandler Heights E. Riggs Rd. 9 3 Green Ln. 9 PRESCOTT McDowell Rd. McKellips Brown 8 Power Baseline Meridian Ironwood Willow Creek Rd. Miller Valley Rd. COTTOWOOD. Pinal Ave. CASA GRADE W. McCartney Rd. 38 orth. Arizola Rd. 84 E. Florence Blvd. 8 Gila Bend Hwy S. Peart Rd. W. Jimmie Kerr Blvd. PRESCOTT VALLE S. Calvary Way 3 W. Selma Hwy 84 E. Florentine Rd. 30 SEDOA 8 69 Rd. Rigby
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