Fillable 2021-22 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

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2021-22 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

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ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Urgent
Care of the Arizona
Interscholastic Association
2021-22 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION
(The parent or guardian should fill out this form with assistance from the student-athlete)
Exam Date: _________________
Name: __________________________________________________________
Home Address: ___________________________________________________
Phone: __________________________________________________________
Date of Birth: ____________________________________________________
Age: ____________________________________________________________
Gender: _________________________________________________________
Grade: __________________________________________________________
School: __________________________________________________________
Sport(s): _________________________________________________________
Personal Physician: _______________________________________________
Hospital Preference: ______________________________________________
In case of emergency contact:
Name: ______________________________
Relationship: _________________________
Phone (Home): _______________________
Phone (Work): ________________________
Phone (Cell): _________________________
Name: ______________________________
Relationship: _________________________
Phone (Home): _______________________
Phone (Work): ________________________
Phone (Cell): _________________________
Explain “Yes” answers on the following page.
Circle questions you don’t know the answers to.
Y N
1) Has a doctor ever denied or restricted your participation in sports for any reason?
2) Do you have an ongoing medical conditional (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 stringing 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 a 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, check affected area in the box below in question 11)
10) Have you had any broken/fractured bones or dislocated joints?
(If yes, check affected area in the box below in question 11):
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, check affected area in the box below):
Head Neck Shoulder Upper Arm Elbow Forearm
Hand/Fingers Chest Upper Back Lower Back Hip Thigh
Knee Calf/Shin Ankle Foot/Toes
FORM 15.7-A 07/01/2018
NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.
1
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Urgent
Care of the Arizona
Interscholastic Association
FORM 15.7-A 07/01/2018
NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.
2
Y N
12) Have you ever had a stress fracture?
13) Have you ever 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 medication?
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) Have you ever had numbness, tingling or weakness in your arms or legs after being hit, falling,
stingers or burners?
26) While exercising in the heat, do you have severe muscle cramps or become ill?
27) Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?
28) Have you ever been tested for sickle cell trait?
29) Have you had any problems with your eyes or vision?
30) Do you wear glasses or contact lenses?
31) Do you wear protective eyewear, such as goggles or a face shield?
32) Are you happy with your weight?
33) Are you trying to gain or lose weight?
34) Has anyone recommended you change your weight or eating habits?
35) Do you limit or carefully control what you eat?
36) Do you have any concerns that you would like to discuss with a doctor?
Y N
37) Have you ever had a menstrual period?
38) How old were you when you had your
first menstrual period? _______
39) How many periods have you had in the
last year? _______
Females Only Explain “Yes” Answers Here
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Urgent
Care of the Arizona
Interscholastic Association
FORM 15.7-A 07/01/2018
NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.
3
2021-22 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION
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
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...
Y N
8) Are there any family members who had sudden/unexpected/unexplained death before age 50? (including SIDS, car accidents
drowing 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 Y N
Enlarged Heart Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Hypertrophic Cardiomyopathy (HCM) Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
Dilated Cardiomyopathy (DCM) Marfan Syndrome (Aortic Rupture)
Heart Rhythm Problems Heart Attack, Age 50 or Younger
Long QT Syndrome (LQTS) Pacemaker or Implanted Defibrillator
Short QT Syndrome Deaf at Birth
Brugada Syndrome
Explain “Yes” Answers Here
I hereby state that, to the best of my knowledge, my answers to all of the above questions are complete and correct. Further-
more, 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/ND/NMD/NP/PA-C/CCSP Date
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Urgent
Care of the Arizona
Interscholastic Association
2021-22 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: ____________________________
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 01/14/2019 (rev.) NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Urgent
Care of the Arizona
Interscholastic Association
2021-22 CONSENT TO TREAT FORM
Parental consent for minor athletes is generally required for sports medicine services, defined as services including,
but not limited to, evaluation, diagnosis, first aid and emergency care, stabilization, treatment, rehabilitation and
referral of injuries and illnesses, along with decisions on return to play after injury or illness. Occasionally, those
minor athletes require sports medicine services before, during and after their participation in sport-related activities,
and under circumstances in which a parent or legal guardian is not immediately available to provide consent
pertaining to the specific condition affecting the athlete. In such instances it may be imperative to the health and
safety of those athletes that sports medicine services necessary to prevent harm be provided immediately, and not
be withheld or delayed because of problems obtaining consent of a parent/guardian.
Accordingly, as a member of the Arizona Interscholastic Association (AIA), ___________________________________ (name
of school or district) requires as a pre-condition of participation in interscholastic activities, that a parent/guardian
provide written consent to the rendering of necessary sports medicine services to their minor athlete by a qualified
medical provider (QMP) employed or otherwise designated by the school/district/AIA, to the extent the QMP deems
necessary to prevent harm to the student-athlete. It is understood that a QMP may be an athletic trainer, physician,
physician assistant or nurse practitioner licensed by the state of Arizona (or the state in which the student-athlete
is located at the time the injury/illness occurs), and who is acting in accordance with the scope of practice under
their designated state license and any other requirement imposed by Arizona law. In emergency situations, the QMP
may also be a certified paramedic or emergency medical technician, but only for the purpose of providing emergency
care and transport as designated by state regulation and standing protocols, and not for the purpose of making
decisions about return to play.
PLEASE PRINT LEGIBLY OR TYPE
“I, _____________________________________, the undersigned, am the parent/legal guardian of,
__________________________________, a minor and student-athlete at _____________________________________________
(name of school or district) who intends to participate in interscholastic sports and/or activities.
I understand that the school/district/AIA employs or designates QMP’s (as defined above) to provide sports medicine
services (as also defined above) to the school’s interscholastic athletes before, during or after sport-related activities,
and that on certain occasions there are sport-related activities conducted away from the school/district facilities
during which other QMP’s are responsible for providing such sports medicine services. I hereby give consent to any
such QMP to provide any such sports medicine services to the above-named minor. The QMP may make decisions
on return to play in accordance with the defined scope of practice under the designated state license, except as
otherwise limited by Arizona law. I also understand that documentation pertaining to any sports medicine services
provided to the above-named minor, may be maintained by the QMP. I hereby authorize the QMP who provides
such services to the above-named minor to disclose such information about the athlete’s injury/illness, assessment,
condition, treatment, rehabilitation and return to play status to those who, in the professional judgment of the QMP,
are required to have such information in order to assure optimum treatment for and recovery from the injury/illness,
and to protect the health and safety of the minor. I understand such disclosures may be made to above-named
minor’s coaches, athletic director, school nurse, any classroom teacher required to provide academic
accommodation to assure the student-athlete’s recovery and safe return to activity, and any treating QMP.
If the parent believes that the minor is in need of further treatment or rehabilitation services for the injury/illness,
the minor may be treated by the physician or provider of his/her choice. I understand, however, that all decisions
regarding same day return to activity following injury/illness shall be made by the QMP employed/designated by the
school/district/AIA.
Date: ______________________ Signature: ____________________________________________________________
FORM 15.7-D 03/04/2019
NextCare is the preferred partner of the AIA. It is not required you visit NextCare locations for your healthcare needs.
1
ARIZONA INTERSCHOLASTIC ASSOCIATION
7007 N. 18TH ST., PHOENIX, ARIZONA 85020-5552
PHONE: (602) 385-3810
The Preferred Urgent Care
of the Arizona Interscho-
lastic Association
COVID-19...
Y N
1) Has your child been diagnosed with COVID-19?
1a) If yes, is your child still having symptoms from their COVID-19 infection?
2) Was your child hospitalized as a result for complications of COVID-19?
3) HasyourchildbeendiagnosedwithMulti-InammatorySyndromeinChildren(MIS-C)?
4) Did your child have any special tests ordered for their heart or lungs or were referred to a heart specialist (cardiologist)
to be cleared to return to sports?
5) Has your child returned back to full participation in sports?
6) Has your child had direct or known exposure to someone diagnosed with COVID-19 in the past 3 months?
6a) Was your child tested for COVID-19?
7) Did your child receive the COVID-19 vaccine?
7a) What was the manufacturer of the vaccine? __________________________________________
7b) Date of vaccination(s) __________________________
Explain “Yes” Answers Here
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2021-22 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

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Completed 16 August 2021

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