ARIZONA BOXING AND MIXED MARTIAL ARTS COMMISSION

PHYSICAL EXAM
PHYSICAL EXAMINATION FOR UNARMED COMBATANT

Applicant Phone: (______)________-__________

APPLICANT INFORMATION
 MALE  FEMALE
Applicant
Last Name First Name Middle Date of Birth
Street Address City State Zip

PHYSICAL HISTORY
Has applicant had any of the following conditions:
 Fainting spells  Rupture (hernia)  Chest pain  Operations
 Shortness of breath  Swollen joints  Rheumatism  Diabetes
 Frequent head aches  Convulsions (fits)  Chronic cough  Bleeding disorder
 Spitting blood  Cerebral hemorrhage or any other serious injury
Number of knockouts received Date of last knockout
Longest duration of unconsciousness
Have you ever been knocked unconscious in any other sport or in any other way?  Yes  No
If yes, explain:

BOXING / UNARMED COMBAT RECORD

Pro Boxing Wins______ Losses______ Draws_______
Pro MMA Wins______ Losses______ Draws_______
Amateur MMA Wins______ Losses______ Draws_______

PHYSICAL EXAMINATION
General appearance Height Weight Temperature
Disabling scars Mouth Teeth Tonsils Neck
Pulse at rest Blood pressure at rest
Pulse after 100 hops Blood pressure after 100 hops
Blood pressure 2 minutes later
Enlarged glands  Yes  No Goiter  Yes  No
Heart: Pulse rhythm  Regular  Irregular Apical impulse  Heavy  Normal
Enlargement  Yes  No Murmurs  Yes  No
Lungs: Rales  Yes  No
Breasts: Mass  Yes  No Tenderness  Yes  No Discharge  Yes  No
Abdomen: Enlargement of liver  Yes  No Enlargement of spleen  Yes  No
Hernia Yes  No Enlargement of spleen  Yes  No
Testicles: Normal  Yes  No Remarks:
Pelvic: Normal  Yes  No Remarks:
Reflexes: Pupils Knee jerks Romberg Babinski
Skin: Rash Boils Any other unhealed wounds:
Speech: Slurred?  Yes  No Other:
General issues (memory, judgment):
Remarks:

1110 West Washington, Suite 450

Phoenix, Arizona 85007
ADG/BM102 (09/2018) Phone: (602) 364-1721 Fax: (602) 255-3883 Page 1 of 2
Website: https://boxingandmma.az.gov
PHYSICAL EXAMINATION

EYE HISTORY
Has applicant every had any of the following conditions:
1. Blurred vision?  Yes  No
2. Surgical procedures done to his/her eye(s) or the tissues around the eye other than simple sutures of the skin around the eye?
 Yes  No
3. Has applicant ever been informed by a physician that he/she had significant eye problems such as retinal detachment, retinal
tear, primary or secondary glaucoma, aphakia, pseudophakia lens?  Yes  No

EYE EXAMINATION
Vision without glasses Vision with glasses Visual Field
Left Right Left Right Left Right

SEROLOGY
THE ORIGINAL REQUIRED LAB REPORT WITH APPLICANT’S NAME AND DATE THE TEST WAS PERFORMED MUST BE
SUBMITTED.

REQUIRED LAB REPORTS TO INCLUDE: HIV, Hepatitis B (Surface Antigen) and Hepatitis C (Antibody)

EXAMINING PHYSICIAN (MUST BE AN MD OR DO PHYSICIAN)

I have examined the above named subject and I  HAVE  HAVE NOT medically cleared to fight.
Remarks:

PHYSICIAN’S NAME / LICENSE # (PLEASE PRINT) SIGNATURE BY (MD or DO) ONLY DATE

OFFICE NAME

STREET ADDRESS

( )
CITY STATE ZIP CODE PHONE NUMBER

*MEDICAL RELEASE AUTHORIZATION BY APPLICANT*

I AUTHORIZE any physician to release to the Arizona Boxing and MMA Commission any of my medical records in his/her
possession. I also authorize the Arizona Boxing and MMA Commission to release any medical information or other personal
information with respect to my status and licensure as a professional boxer or unarmed combatant which may be contained
in any of its records to other State Commissions. I agree that a photographic copy of this authorization shall be valid as the
original. I agree that this authorization will be valid for a period of one year from the date indicated in this document.

NAME OF APPLICANT (PLEASE PRINT) APPLICANT’S SIGNATURE DATE

1110 West Washington, Suite 450

Phoenix, Arizona 85007
ADG/BM102 (09/2018) Phone: (602) 364-1721 Fax: (602) 255-3883 Page 2 of 2
Website: https://boxingandmma.az.gov
ARIZONA BOXING AND MIXED MARTIAL ARTS COMMISSION
DILATED EYE EXAM
REPORT OF EYE EXAMINATION FOR
PROFESSIONAL BOXER / UNARMED COMBATANT
TO BE PERFORMED
BY AN OPTOMETRIST OR OPHTHALMOLOGIST

Last Name First Name Middle Date of Birth

Street Address City State Zip
 BOXER Boxing Record: ______________  MMA FIGHTER: MMA Record: _______________

HISTORY
If possible provide the following information:
Name and hometown of physician in charge:
Has applicant ever had any of the following conditions:
1. Blurred vision  Yes  No
2. Surgical procedures done to his/her eye(s) or the tissues around the eye other than simple sutures of the skin around the
eye?  Yes  No
3. Has applicant ever been informed by a physician that he/she had significant eye problems such as retinal detachment, retinal
tear, primary or secondary glaucoma , aphakia, pseudophakia, dislocated lens, or cataract?  Yes  No
If yes, please explain:

4. Eye disease:  Yes  No List nature of disease:

5. Eye injury:  Yes  No List nature of injury:
6. Detached retina surgery on either eye:  Yes  No
List which eye and when and where surgery was done:

EXAMINATION
VISION: Without With REFRACTION: If either eye is 20/40 or worse:
Glasses
Right Right Sph Cyl x Acuity
Left Left Sph Cyl x Acuity

Intraocular Right mmHg

Tension Left mmHg Remarks: _______________________________
Motility Normal Abnormal _______________________________
Binocular Vision Normal Abnormal _______________________________

SLIT LAMP EXAM NORMAL ABNORMAL SPECIFIC ABNORMALITIES

Right Left Right Left
Conjunctiva
Cornea    
Iris/Pupil    
Lens    
Eyelids    

INDIRECT OPHTHALMOSCOPY WITH SCLERAL DEPRESSION (Dilated Pupil)

NORMAL ABNORMAL SPECIFIC ABNORMALITIES
Right Left Right Left
Disc    
Macula    
Vessels    
Peripheral Retina    

1110 West Washington, Suite 450

Phoenix, Arizona 85007
Phone: (602) 364-1721 Fax: (602) 255-3883
ADG/BM103 (09/2018) Website: https://boxingandmma.az.gov
DILATED EYE EXAM
PAGE 2

The Commission shall deny, suspend, revoke, or place restrictions on the license of a professional boxer or martial arts
fighter because of a medical or visual condition, (The Commission may also place restrictions for the same medical
conditions on all amateur combatants under its jurisdiction) including but not limited to the following:

1. Uncorrected visual acuity of less than 20/200 in either eye or 20/60 with both eyes;
2. Corrected visual acuity of less than 20/60 in either eye, regardless of its cause;
3. A visual field of 60 degrees or less extending over one or more quadrants of the visual field;
4. Presence or history of retinal detachment or retinal tear unless treated by an ophthalmologist and then approved
by an ophthalmologist specified by the Commission who then assesses that the boxer is at no significant risk of
further injury to the retina if boxing is resumed. Such assessment shall occur both within five days before and five
days after the contest;
5. Presence of primary or secondary glaucoma, whether or not such condition has been treated;
6. Presence of aphakia, pseudophakia, dislocated lens or cataract in either eye;
7. Any other visual condition which the Commission determines would prevent the applicant or licensee from safely
engaging in boxing activities.

The examining physician is requested to mail or fax a copy of any report, directly to the Commission of an applicant that
has a condition that may preclude him/her from being licensed or cleared to participate in any combat activities.

REPORT OF EYE EXAMINATION FOR PROFESSIONAL BOXER / UNARMED COMBATANT

PHYSICIAN REMARKS:

OPTOMETRIST OR OPHTHALMOLOGIST MUST COMPLETE ALL ITEMS LISTED BELOW

I have read the above criteria and, in accordance with the vision requirements as stated therein, have
examined the applicant named on page 1 and page 2 of this form and
I  HAVE  HAVE NOT medically cleared him/her to compete as a licensed boxer/unarmed combatant.

PHYSICIAN NAME / LICENSE # (please print) PHYSICIAN SIGNATURE

OFFICE NAME AND STREET ADDRESS DATE

( )
CITY STATE ZIP CODE PHONE NUMBER

* MEDICAL RELEASE AUTHORIZATION BY APPLICANT *

I AUTHORIZE any physician to release to the Arizona Boxing and MMA Commission any of my medical records in his/her
possession. I also authorize the Arizona Boxing and MMA Commission to release any medical information or other personal
information with respect to my status and licensure as a professional boxer or unarmed combatant which may be contained
in any of its records to other State Commissions. I agree that a photographic copy of this authorization shall be valid as the
original. I agree that this authorization will be valid for a period of one year from the date indicated in this document.

SIGNATURE OF APPLICANT DATE

( )
NAME PRINTED PHONE NUMBER

ANY ATTEMPT TO ALTER OR FALSIFY THIS DOCUMENT WILL RESULT IN FORFIETURE OF LICENSE AND/OR
PROSECUTION IN A CRIMINAL COURT OF LAW.

1110 West Washington, Suite 450

Phoenix, Arizona 85007
Phone: (602) 364-1721 Fax: (602) 255-3883
ADG/BM103 (09/2018) Website: https://boxingandmma.az.gov