SPORTS MEDICINE MEDICAL HISTORY
|
|
- Dorothy Bradford
- 8 years ago
- Views:
Transcription
1 SPORTS MEDICINE MEDICAL HISTORY Complete all forms in this packet and return to: Mary McLendon, ATC or fax: or mail: P.O. Box 5327, Mississippi State, MS Read the directions before each section CAREFULLY. Any incomplete packets and/or packets missing signatures will be returned. Student-athletes will not be allowed to participate until all forms are fully completed. If you have any questions, please contact: Mary McLendon, ATC
2 MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE MSU Sports Medicine March 2015 PRE-PARTICIPATION PHYSICAL EXAMINATION PROCEDURES AND GENERAL MEDICAL INFORMATION The Mississippi State University Athletic Department seeks to provide comprehensive athletic training services for its student-athletes, including preventive services, first aid, and physical rehabilitation. While your child is at Mississippi State, their health will be our main concern. Visit our website to learn more about our program; you ll find information about our staff, the pre-participation physicals process, and our facilities. The website can be accessed by clicking on the Sports Medicine link under Departments at Please do not hesitate to contact your child s athletic trainer if you have any questions throughout the year regarding their health; however, we encourage the student-athlete to be the first line of communication. We can provide the best care for the student-athlete when there is open and honest communication between them and their athletic trainer. Our contact information (sport assignment, phone number, address, etc.) can be found by visiting our website. Medical Certification for Individual Student-Athlete Participation: The Mississippi State University Athletic Department requires all student-athletes to complete a preparticipation physical examination prior to the student-athlete being issued equipment, being permitted to attend any practice or strength and conditioning session, and/or competing in any intercollegiate athletic activities. The pre-participation physical examination MUST be administered by a Mississippi State University Team Physician. The examination includes, but is not limited to: 1. Completion of the John C. Longest Student Health Center Health History Questionnaire (enclosed); Checklist: Completed both sides form Student-athlete signed the consent to treat (a parent should not sign unless the student-athlete is a minor) 2. Completion of the Mississippi State University Student-Athlete Health History (enclosed); Checklist: Completed both sides form Leave local address blank if you do not have an MSU/Starkville address yet Completed TDAP section If the student-athlete has had a TDAP (tetanus with pertussis) shot within the last five years, please have the medical facility or doctor who gave the shot fill in when the shot was administered and sign and stamp the form. If the TDAP shot is included on an official shot record, that will be acceptable. If we do not have proof of a TDAP shot within the past five years, the student-athlete will be required to receive a TDAP shot at physicals here on campus. We do not want to give repeat shots, so completing this information is very important. Provided information for eye doctor (if applicable) Answered all questions and gave explanations for any Yes responses Student-athlete signed the bottom of form
3 MSU Sports Medicine March Completion of the Mississippi State University New Female Student-Athlete Health History (enclosed, complete if applicable); Checklist: Answered all questions and gave explanations for any Yes responses Student-athlete signed form 4. Completion of the HIPAA Notice of Provider Privacy Practices (enclosed); This includes information about the HIPAA privacy practices for the Longest Student Health Center. You don t need to worry about the receipt mentioned at the top of the first page; the receipt is included at the bottom of the first form you completed. 5. Completion of the Consent to Treat Minor Patient Form (enclosed, complete if applicable); This form needs to be completed only if the student-athlete will not be 18 at their time of the on campus physical examination. 6. Completion of the NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment with Banned Stimulant Medication) (enclosed, complete if applicable); This form needs to be completed only if the student-athlete is using any medicine for the treatment of ADD/ADHD (see ADHD Medications below for additional information). 7. Completion of the MMR Immunization/ Shot Record (separate mailing); This form is sent to all students and will come directly from the university. Although we do not include it in this packet, it is very important to complete this form and return it to the school. If you need another copy of this form, you can print it at: 8. Completion of the Mississippi State University Department of Athletics Health Insurance Information/Authorization Form (separate mailing); 9. Completion of an Athletic Medical Examination and Orthopaedic Screening Examination by a Mississippi State University Team Physician and/or his/her designee; 10. Completion of a blood test as mandated by the NCAA for sickle cell trait/sickle cell anemia. The results of this test can take as long as hours, and student-athletes cannot begin participation until the results are received. Selected individuals may be required to complete additional tests and/or examinations as needed. Upon successful completion of the aforementioned pre-participation physical examination process, the student-athlete will receive approval/certification from MSU Sports Medicine and the Compliance Office to be issued equipment, and to participate in practice, strength and conditioning sessions, and/or competition. If, for any reason, the student-athlete is not approved/ certified for intercollegiate athletics participation, he/she will be notified by the Mississippi State University Team Physician and/or a member of the Mississippi State University Sports Medicine Department at the end of the preparticipation physical examination. Scholarship Student-Athletes: - Costs associated with any additional tests, consultations, and/or medical procedures needed to gain approval/certification for participation will be sent to the student-athlete s primary health insurance for payment first. - Costs not paid by the student-athlete s primary health insurance will be paid through the Mississippi State University Athletic Department.
4 MSU Sports Medicine March 2015 Non-scholarship/Walk-on/Tryout Student-Athletes: - All costs associated with any additional tests, consultations, and/or medical procedures needed to gain approval/certification for participation in intercollegiate athletics at Mississippi State University will be the responsibility of the student-athlete and/or his/her primary health insurance. No member of the Mississippi State University Athletic Department will permit a student-athlete to participate, nor will Mississippi State University provide insurance coverage to any student-athlete who has not completed the pre-participation physical examination procedure. Scheduling a Physical Examination (Scholarship Student-Athletes): Coaches will contact scholarship student-athletes and/or their families regarding specific dates and times for physicals. ADHD Medications: The NCAA bans classes of drugs that can be harmful to student-athletes and that can create unfair advantages during competition (NCAA Bylaw ). Some medications that student-athletes are prescribed for legitimate medical reasons contain NCAA banned substances. The NCAA, through the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS) has a procedure to review and approve the use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The NCAA has a strict application of the NCAA Medical Exception policy, specifically for the use of banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD). Student-athletes who have been diagnosed with ADHD and/or have been prescribed stimulant medications should immediately notify a member of the MSU Sports Medicine Staff to begin the process of obtaining the necessary documentation. Student-athletes who have been treated since childhood with ADHD stimulant medications but do not have the pertinent records with regards to the diagnosis, management, and continuing evaluation must undergo a comprehensive evaluation to obtain the necessary documentation. At a minimum, student-athletes must provide the following documentation from the prescribing physician: 1. Description of the evaluation process which identifies the assessment tools and procedures; 2. Statement of the diagnosis, including when it was confirmed; 3. History of ADHD treatment (previous/ongoing); 4. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed; 5. Statement regarding follow-up and monitoring visits; and 6. Copy of the most recent prescription (as documented by the prescribing physician). This documentation should be on file with the MSU Sports Medicine Staff. The student-athlete should come to campus with the documentation or all documentation may be sent to: Mary McLendon, ATC Director of Sports Medicine P.O. Box 5327 Mississippi State, MS Secure Fax- (662) mkm13@msstate.edu
5 Drug Testing and Banned Drugs: MSU Sports Medicine March 2015 The Mississippi State University Department of Intercollegiate Athletics recognizes that drug and alcohol use and abuse is a significant problem in modern society. The abuse of chemical substances poses a serious threat to the physical and psychological well being of student-athletes. The National Collegiate Athletic Association (NCAA) has also recognized this issue and requires that all athletes under its jurisdiction be placed under its drug testing policies and program. The NCAA has established a year round drug testing program that includes on-campus testing as well as testing at all NCAA Championship events. To ensure both the wellbeing of our student-athletes and compliance with NCAA drug use regulations, Mississippi State University has established a year-round, comprehensive drug education and screening program. This program is designed to provide student-athletes with a means of obtaining support, assistance, and direction in dealing with drug and alcohol abuse. The NCAA will also conduct a year-round drug-screening program on campus, at the site of postseason events, and at any other time as determined by the NCAA. Enclosed you will find the most recent NCAA Banned Drugs Handout which will give you more information. The MSU drug testing policy can be reviewed on the MSU Athletics website ( by selecting Athletics then Compliance. You are also welcome to review the policy at my office, and the policy will be included in the Student-Athlete Handbook. I encourage you to review this information. A positive MSU or NCAA drug test for street drugs (including marijuana) or performance enhancing drugs can result in suspension from participation and ultimately a loss of scholarship. Nutritional/Dietary Supplements: The use of supplements has become widespread among athletes, and student-athletes have tested positive and lost their eligibility from using these products. Any supplement product or medication, even those that do not seem to be targeted to athletic performance, needs to be reviewed with the MSU Sports Medicine Staff. The NCAA mandates that each athletic department designate provide a staff member as a resource for questions about dietary supplements and NCAA banned drugs. All inquiries should be directed to the Director of Sports Medicine, Mary McLendon. Before consuming any nutritional/dietary supplement product, review the product and its label with the Director of Sports Medicine. Dietary supplements are not well regulated and may cause a positive drug test result. Even if a product is not known to contain a banned substance, any product containing a dietary supplement ingredient is taken at your own risk. Injury/Illness Reporting Procedures: Any student-athlete who is injured/becomes ill must IMMEDIATELY report the injury/illness to a member of the Mississippi State University Sports Medicine Department. Costs pertaining to an injury and/or illness not reported in a timely manner may be the responsibility of the student-athlete and/or his/her parent(s)/guardian(s). Missed Doctor s Appointment Policy: Student-athletes who are late and/or fail to show-up for scheduled appointments with the team physician, medical consultants, and/or diagnostic test/procedures will be financially responsible for any and all charges resulting from the missed appointment. In addition, the student-athlete may be responsible for rescheduling the appointment and providing his/her own transportation.
6 Contact Lens Policy: MSU Sports Medicine March 2015 Scholarship student-athletes in need of an eye exam and/or contact lenses will be referred to the Team Ophthalmologist/Optometrist by a member of the Mississippi State University Sports Medicine Department. If the doctor determines a need for contact lenses during sports participation, studentathletes will receive a supply of contact lenses. One (1) pair of lenses will be kept by the studentathlete s certified athletic trainer in case of an emergency. If the student-athlete has a current prescription, you are encouraged to transfer the prescription to one of our eye doctors. Your team s athletic trainer can help with that process, and the prescription must be less than one year old. Student-athletes in need of glasses need to contact the Compliance Office to determine if opportunity funds can be used to defray the expense. Out-of-town Physical Therapy/ Rehabilitation Procedures: At times, it may be necessary for a student-athlete to utilize an out-of-town physical therapy facility. In such situations, permission must be granted from the Director of Sports Medicine and/or her designee. Such referrals must come from a member of the Mississippi State University Sports Medicine Department. If a student-athlete decides to utilize physical therapy/rehabilitation services without the authorization of a member of the Mississippi State University Sports Medicine Department, the student-athlete and/or the student athlete s parent(s)/guardian(s) will be financially responsible for any and all medical bills incurred. Physician Referrals/Consultations: The Mississippi State University Athletic Department and MSU Sports Medicine have fostered positive relationships with many medical providers who have consistently provided high quality service to Mississippi State University student-athletes. Members of the Mississippi State University Sports Medicine Staff will refer student-athletes to these providers, unless extenuating circumstances necessitate a different provider. Student-athletes with HMO policies are strongly encouraged to have a local primary care physician (PCP), so that timely care can be given. All student-athletes must be seen and evaluated by a Mississippi State University certified athletic trainer before a referral to a physician will be made. A member of the Mississippi State University Sports Medicine Department must authorize and properly refer all student-athletes to see a physician or medical consultant, and/or for diagnostic tests. If a student-athlete decides to see a physician/medical consultant, and/or undergo a diagnostic test WITHOUT prior authorization/referral from a member of the Mississippi State University Sports Medicine Department, the student-athlete and/or the student athlete s parent(s)/guardian(s) will be financially responsible for any and all medical bills incurred. Medical Second Opinions: If a student-athlete and/or his/her parent(s)/guardian(s) desire another physician s opinion on a medical injury/illness, the student-athlete and/or the student athlete s parent(s)/ guardian(s) are financially responsible for any and all medical bills incurred, including but not limited to office visit charges, travel, and additional testing. The student-athlete will also be responsible for acquiring any requested medical records.
7 MSU Sports Medicine March 2015 Additional Information for Non-Scholarship/Walk-On Student-Athletes: All non-scholarship student-athletes are required to have coverage under a personal health insurance plan. The Mississippi State University Athletic Department will only take responsibility for injuries sustained while participating in a supervised workout, practice, game, or team travel and will not take responsibility for any expenses until your deductible has been reached. Any amount up to your deductible is the responsibility of the student-athlete and/or the parent(s)/guardian(s). For additional information, please review the Health Insurance Information that came with your Health Insurance Information/Authorization Form (separate mailing). KEEP THIS LETTER FOR YOUR RECORDS and direct any questions to: Mary McLendon, ATC Director of Sports Medicine (662) mkm13@msstate.edu
8
9
10 MISSISSIPPI STATE UNIVERSITY STUDENT-ATHLETE HEALTH HISTORY Revised 7/16/03 Calendar Year TO BE COMPLETED BY STUDENT-ATHLETE (PLEASE PRINT CLEARLY) Name Sport Year at MSU: MSU# (9 digits) Marital Status Single Married Date of Birth Gender Male Female Local Address Ethnicity/Race City State Zip Cell Phone# Mother/ Guardian Home Phone # ( ) Address Work Phone # ( ) City State Zip Father/ Guardian Home Phone # ( ) Address Work Phone # ( ) City State Zip TO BE COMPLETED BY THE MSU MEDICAL STAFF Comments: Date of initial physical exam: Student-Athlete needs to be referred to: BP No indication from this questionnaire for referral to physician Orthopaedic General Medical Other Pulse Referred to: Referred to: Referred to: Athletic Trainer Signature, ATC Date, 20 Examination Date: Physician Name ( ) CLEARED TO PARTICIPATE ( ) PRIOR TO PARTICIPATING, STUDENT-ATHLETE REQUIRES: ( ) NOT CLEARED TO PARTICIPATE Physician Signature Date, 20 Examination Date: Physician Name ( ) CLEARED TO PARTICIPATE ( ) PRIOR TO PARTICIPATING, STUDENT-ATHLETE REQUIRES: ( ) NOT CLEARED TO PARTICIPATE Physician Signature Date, 20
11 MISSISSIPPI STATE UNIVERSITY STUDENT-ATHLETE HEALTH HISTORY STUDENT-ATHLETE S NAME This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The NCAA s policies recommend all student-athletes have a qualifying medical evaluation upon initial entrance into an institution s intercollegiate athletic program and an annual health-status review. Mississippi State University supports this NCAA policy. Further medical evaluations may be required for specific matters. NEW STUDENT-ATHLETES: If you have had a TDAP shot within the last 5 years, please provide: Date of last TDAP shot: _ / / Physician Signature or Clinic Stamp: Yes No Do you wear eyeglasses or contact lenses? (circle one or both) Date of Last Exam: Name and Phone Number for Prescriber: NEW STUDENT-ATHLETES: Have you ever had the following: RETURNING STUDENT-ATHLETES: In the past year have you had the following: If you answer Yes to any of the following, please provide a brief explanation and the date of the injury. 1. Yes No Major illness or hospitalization? 2. Yes No Illness lasting over 1 week? 3. Yes No Any operations or surgery? 4. Yes No Missing organs? (eye, kidney, testicle, etc.) 5. Yes No Allergy to any medication or food? 6. Yes No Problems with heart (i.e. heart murmur) or blood pressure? 7. Yes No Dizziness, fainting, frequent headaches, convulsions, or fatigue? 8. Yes No Shortness of breath or chest pain with exercise? 9. Yes No Dizziness, faintness, or headaches with exercise? 10. Yes No Heat exhaustion, heat stroke, or other heat problems? 11. Yes No Neck injury, head injury, concussion, or unconsciousness? 12. Yes No Knee injury, ankle injury, or surgeries? 13. Yes No Other serious joint injury, broken bones, or injury requiring a physician s treatment? 14. Yes No Do you wear any braces, dental bridges, or dental plates? 15. Yes No Do you currently have any incompletely healed injury? 16. Yes No Are you taking any medication on a regular basis? 17. Yes No Has any family member died suddenly at less than 40 years of age of causes other than an accident? Relation: 18. Yes No Has any family member had a heart attack at less than 55 years of age? Relation: 19. Yes No Has any family member been diagnosed with Marfan s Syndrome? Relation: 20. Yes No Has any family member had a problem with alcohol? Relation: 21. Yes No RETURNING ATHLETES ONLY: Would you like to discuss your current health with a team physician? The undersigned, herewith: A. Understands he/she must refrain from practice while ill or injured, whether or not receiving medical treatment, until discharged from treatment or given permission by the clinical practitioner to resume participation despite continuing treatment. B. Understands having passed the physical examination does not necessarily mean that he/she is physically qualified to engage in athletics, but only that the evaluation did not find a medical reason warranting disqualification at the time of said examination. C. Certifies the answers to the questions above are correct and true. Student-Athlete Signature Date
12
13
14 NCAA Banned Drugs It is your responsibility to check with the appropriate or designated athletics staff before using any substance The NCAA bans the following classes of drugs: a. Stimulants b. Anabolic Agents c. Alcohol and Beta Blockers (banned for rifle only) d. Diuretics and Other Masking Agents e. Street Drugs f. Peptide Hormones and Analogues g. Anti-estrogens h. Beta-2 Agonists Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned drug class regardless of whether they have been specifically identified. Drugs and Procedures Subject to Restrictions: a. Blood Doping. b. Local Anesthetics (under some conditions). c. Manipulation of Urine Samples. d. Beta-2 Agonists permitted only by prescription and inhalation. e. Caffeine if concentrations in urine exceed 15 micrograms/ml. NCAA Nutritional/Dietary Supplements Warning: Before consuming any nutritional/dietary supplement product, review the product with the appropriate or designated athletics department staff! Dietary supplements are not well regulated and may cause a positive drug test result. Student-athletes have tested positive and lost their eligibility using dietary supplements. Many dietary supplements are contaminated with banned drugs not listed on the label. Any product containing a dietary supplement ingredient is taken at your own risk.
15 Note to Student-Athletes: There is no complete list of banned substances. Do not rely on this list to rule out any supplement ingredient. Check with your athletics department staff prior to using a supplement. Some Examples of NCAA Banned Substances in Each Drug Class Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); methylhexaneamine, bath salts (mephedrone) etc. exceptions: phenylephrine and pseudoephedrine are not banned. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): Androstenedione; boldenone; clenbuterol; DHEA (7-Keto); epi-trenbolone; etiocholanolone; methasterone; methandienone; nandrolone; norandrostenedione; stanozolol; stenbolone; testosterone; trenbolone; etc. Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (eg. spice, K2, JWH-018, JWH-073) Peptide Hormones and Analogues: growth hormone(hgh); human chorionic gonadotropin (hcg); erythropoietin (EPO); etc. Anti-Estrogens : anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene(ATD), etc. Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc. Additional examples of banned drugs can be found at Any substance that is chemically related to the class, even if it is not listed as an example, is also banned! Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center, REC, or password ncaa1, ncaa2 or ncaa3. It is your responsibility to check with the appropriate or designated athletics staff before using any substance. The National Collegiate Athletic Association June 2013 MEW
16
17 NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment with Banned Stimulant Medication Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication. Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Drug Testing Exceptions Procedures at To be completed by the Institution: Institution Name: Institutional Representative Submitting Form: Name Title Phone Student-Athlete Name Student-Athlete Date of Birth To be completed by the Student-Athlete s Physician: Current Treating Physician (print name): Specialty: Office address Physician signature: Date Check off that documentation representing each of the items below is attached to this report o Diagnosis. o Medication(s) and dosage. o Blood pressure and pulse readings and comments. o Note that alternative non-banned medications have been considered, and comments. o Follow-up orders. o Date of clinical evaluation: o Attach written report summary of comprehensive clinical evaluation. Please note that this includes the original clinical notes of the diagnostic evaluation. The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores. The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.
18 MSU SPORTS MEDICINE STUDENT-ATHLETE CONCUSSION STATEMENT (To be signed annually) August 1 st, 2010 Revised August 2011 September 2013 I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, I am aware of the following information: Initial Initial Initial A concussion is a brain injury, which I am responsible for reporting to my physician or athletic trainer. A concussion can affect my ability to perform everyday activities and affect reaction time, balance, sleep, and classroom performance. You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Common signs and symptoms of a concussion include: Initial - Amnesia - Confusion - Headache - Loss of consciousness - Nausea - Double or fuzzy vision - Sensitivity to light or noise - Balance problems or dizziness - Feeling unusually irritable - Feeling sluggish, foggy, or groggy - Slowed reaction time - Concentration or memory problems If I experience any of these signs or symptoms or in any way suspect I have suffered a concussion, I am responsible for reporting this to my team physician or athletic trainer. Initial Initial Initial Initial If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms. Following a concussion, the brain needs time to heal. I understand I am much more likely to have a repeat concussion if I return to play before my symptoms resolve. I understand repeat concussions can cause permanent brain damage and even death. PRINT NAME SIGNATURE DATE SIGNATURE OF PARENT OR GUARDIAN IF UNDER 18
19 CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that: Can happen even if you do not lose consciousness. HOW CAN I PREVENT A CONCUSSION? Basic steps you can take to protect yourself from concussion: WHAT ARE THE SYMPTOMS OF A CONCUSSION? WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don t hide it.. Report it. Get checked out. Take time to recover. IT S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.
20 MSU Sports Medicine Revised April 2015 MISSISSIPPI STATE UNIVERSITY FEMALE ATHLETE HEALTH HISTORY This form should be completed and signed by the athlete prior to her physical examination. All answers are confidential within the Sports Medicine team. Menstrual Health 1. At what age did you begin competitive training for your sport? years old 2. How old were you when you had your first menstrual period? years old 3. How often do you have your period? Every days 4. How long do your periods last? days 5. How many periods have you had in the last 12 months? 6. When was your last period? / / 7. Do you ever have trouble with heavy bleeding? Yes No 8. Do you ever experience cramps during your period? How do you treat them? Yes No 9. Do you take birth control pills or hormones? Name of the prescription? Yes No 10. Have you ever been pregnant? Yes No 11. Do you have any unusual vaginal discharge? Yes No 12. Have you ever had a pelvic exam/ pap? Date of your most recent pelvic exam? Yes No / / 13. Have you ever had an abnormal pap smear? Yes No 14. How many urinary tract infections (bladder or kidney) have you had? Nutrition 15. Have you ever been treated for anemia? Yes No 16. How many meals do you eat each day including snacks? 17. How do you rate your diet? Excellent Good Fair Poor 18. Are you on a special diet or do you avoid certain types of foods or food groups? (e.g. meats, bread)? 19. List everything you have eaten in the last 24 hours 20. Have you ever been on a weight loss diet? Yes No 21. What is your current Height? Weight? Dress size? ft. in./ lbs./ Clothing size 22. How much of an issue for you is your weight? 23. Do you consciously watch your weight for your sport? Yes No 24. Are you preoccupied with thinking about food during the season? Yes No 25. How often are you dieting during the season? 25. Are you trying to gain or lose weight? Gain Lose Neither 26. Are you happy with your present weight? If not, what would you like to weigh? Yes No lbs. 25. Has anyone recommended that you gain or lose weight? Yes No Who? 27. Do you have any questions about healthy ways to control weight? Yes No
21 MSU Sports Medicine Revised April Have you ever tried to control your weight by vomiting? Yes No fasting? Yes No using laxatives? Yes No using diuretics? Yes No using diet pills? Yes No 33. Have you ever eaten a large amount of food rapidly and felt that this eating incident was excessive and out of control (aside from holiday feasts)? How often has this happened in the past year? Yes No times 34. Do you feel like you lose control of yourself when eating? Yes No 36. Have you ever been diagnosed as having an eating disorder? Yes No General Health 35. Do you often exercise in addition to your team workouts? Yes No 36. Have you ever had a stress fracture? If yes, please list the location(s) Yes No 36. Have you ever been told you have low bone density (osteopenia or osteoporosis)? Yes No 37. List any questions you may have about medications, diet, weight gain/loss, or any other health matters: Use this space to explain any of the above YES answers and to provide any additional information; a second page may be used. Question # Comments Signature of Athlete / / Date Print Name Signature of MSU Athletic Trainer / / Date
Defiance College Athletic Department. Substance Abuse Prevention Program (SAPP) Policy Manual
Defiance College Athletic Department Substance Abuse Prevention Program (SAPP) Policy Manual Aug. 2011 DEFIANCE COLLEGE ATHLETIC DEPARTMENT SUBSTANCE ABUSE PREVENTION PROGRAM Policy Manual PURPOSE: In
More informationDear Parent/Guardian,
Dear Parent/Guardian, On behalf of the Saint Joseph s College Sports Medicine Department welcome back, we are very excited to have your son/daughter as a student-athlete at Saint Joseph s College for the
More informationAthletics Substance Abuse Education and. Drug Testing Policies and Procedures 2014-2015. Revised 11-17-2014
Athletics Substance Abuse Education and Drug Testing Policies and Procedures 2014-2015 Revised 11-17-2014 Table of Contents 1 P a g e Forward and Statement I. Education II. Substance Abuse Committee III.
More informationUniversity of Tennessee Knoxville Department of Intercollegiate Athletics. Substance Abuse Testing Policy and Procedures
University of Tennessee Knoxville Department of Intercollegiate Athletics Substance Abuse Testing Policy and Procedures Revised 07/2012 2 Table of Contents Introduction 3 Scope 4 Definitions 4 Education
More informationFlorida Atlantic University Department of Athletics. Drug and Alcohol Policy (Including Statements on Tobacco and Supplements)
Florida Atlantic University Department of Athletics Drug and Alcohol Policy (Including Statements on Tobacco and Supplements) 2012-2013 Table of Contents Introduction...1 Types of Drug Testing...2 Statement
More informationFURMAN UNIVERSITY SPORTSMEDICINE CENTER
FURMAN UNIVERSITY SPORTSMEDICINE CENTER IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are
More informationPace University Athletics Department Drug Education and Testing Program
Pace University Athletics Department Drug Education and Testing Program This program is designed for the intercollegiate student-athletes at Pace University. This program is in addition to the drug education
More informationDear Alderson Broaddus Student-Athlete:
Dear Alderson Broaddus Student-Athlete: Welcome back for another exciting year at Alderson Broaddus University! In preparation for the beginning of the academic year, and your participation in intercollegiate
More informationUniversity of Delaware Division of Intercollegiate Athletics and Recreation Services. Drug Testing Program. Policy Manual
University of Delaware Division of Intercollegiate Athletics and Recreation Services Drug Testing Program Policy Manual Athletics 2014-2015 Reviewed and Revised August 2014 Table of Contents Page Number
More informationUniversity of California, Irvine Department of Intercollegiate Athletics
I. Introduction: University of California, Irvine Department of Intercollegiate Athletics Alcohol and Drug Education and Testing Program The mission of the UC Irvine Department of Intercollegiate Athletics
More informationDEPARTMENT OF ATHLETICS OFFICE OF SPORTS MEDICINE ALCOHOL, TOBACCO AND DRUG EDUCATION HANDBOOK
DEPARTMENT OF ATHLETICS OFFICE OF SPORTS MEDICINE ALCOHOL, TOBACCO AND DRUG EDUCATION HANDBOOK TABLE OF CONTENTS Overview and Purpose... 3 Alcohol, Tobacco and Other Drug Education... 4 Consent to Participate...
More informationPortland State University Sports Medicine Returning Student Athlete Health Report Form
Portland State University Sports Medicine Returning Student Athlete Health Report Form All the following forms must be completed and submitted to the Sports Medicine Department annually. It needs to be
More informationUNIVERSITY OF CALIFORNIA, RIVERSIDE DEPARTMENT OF INTERCOLLEGIATE ATHLETICS
UNIVERSITY OF CALIFORNIA, RIVERSIDE DEPARTMENT OF INTERCOLLEGIATE ATHLETICS 1. INTRODUCTION DRUG EDUCATION AND PREVENTION PROGRAM Consistent with the University s mission of teaching, research and public
More information2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION
2015-16 CHECKLISTS OF ATHLETIC TRAINING INFORMATION Returning GCU Student Athletes: Until these forms are complete and you have been released to practice by the Athletic Training Staff, you will not be
More informationFlagler College Athletic Department Alcohol, Tobacco and Drug Policy. Reviewed and Revised May 2013
Flagler College Athletic Department Alcohol, Tobacco and Drug Policy Reviewed and Revised May 2013 Table of Contents Introduction 3 Purpose of the Flagler College Institutional Drug Testing Program 3 Eligibility
More informationDepartment of Athletics Institutional Drug Education and Testing Program Policy
Department of Athletics Institutional Drug Education and Testing Program Policy Overview This policy is not to be construed as a contract between the institution and the student-athletes at Daemen College.
More informationDepartment of Athletics Drug/Alcohol Education & Testing Program
Department of Athletics Drug/Alcohol Education & Testing Program 1. Introduction The following policy statement has been adopted and shall be administered by the Loyola University Maryland Athletic Department.
More informationNEW STUDENT-ATHLETE MEDICAL HISTORY FORM
Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency
More informationAll forms are to be completed and returned to: The University of Denver Attn: Sports Medicine, Room 1312 2201 E. Asbury Ave. Denver, CO 80208-3200
Julie Campbell Director of Sports Medicine (303) 871-3918 Office (303) 871-3666 Fax jcampbel@du.edu To: Re: Returning Student-Athletes 2014-2015 Sports Medicine Medical Information Packets Date: Thursday,
More informationELMIRA COLLEGE SPORTS MEDICINE INFORMATION, POLICY AND PROCEDURE MANUAL FOR ATHLETES
ELMIRA COLLEGE SPORTS MEDICINE INFORMATION, POLICY AND PROCEDURE MANUAL FOR ATHLETES Medical Eligibility for Freshman and Transfer Students: All students who wish to participate in intercollegiate athletics
More informationMedical Care & Insurance Procedures
Medical Care & Insurance Procedures Weatherford College (WC) Athletics Department seeks to provide comprehensive athletic training services for its student-athletes, including preventive services, first
More informationAthletic Training Department * 320 S. Main St. * Olivet, Michigan 49076 * Fax (269)-749-4144
Athletic Training Department * 320 S. Main St. * Olivet, Michigan 49076 * Fax (269)-749-4144 Dear Student-Athlete and Parent(s)/Guardian(s): On behalf of the Olivet College Athletic Training Department,
More informationFairfield University Sports Medicine Department 1073 North Benson Road Fairfield, CT 06824
June 1, 2015 The Fairfield University Sports Medicine Department requires that all student athletes complete several forms before they are eligible to participate with their athletic team in the upcoming
More informationMISSISSIPPI STATE UNIVERSITY DEPARTMENT OF INTERCOLLEGIATE ATHLETICS DRUG TESTING AND EDUCATION PROGRAM
MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF INTERCOLLEGIATE ATHLETICS DRUG TESTING AND EDUCATION PROGRAM I. PURPOSE The Mississippi State University Department of Intercollegiate Athletics recognizes that
More informationSTUDENT-ATHLETE DRUG EDUCATION, PREVENTION, REHABILITATION AND SCREENING
STUDENT-ATHLETE DRUG EDUCATION, PREVENTION, REHABILITATION AND SCREENING Neumann University seeks to provide an education that balances the liberal arts with the professions in an environment which promotes
More informationConcussion Information Sheet
Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force
More informationHow To Get Insurance At Central College
CENTRAL COLLEGE PARENT/GUARDIAN/STUDENT INFORMATION FORM 2013-2014 RETURN COMPLETED FORM TO Central College Attn: Frank Neu Campus Box 6600, 812 University St. Pella, IA 50219 If you are filling this out
More informationNORTHWESTERN UNIVERSITY SPORTS MEDICINE DEPARTMENT Medical Care & Insurance Plan Document
NORTHWESTERN UNIVERSITY SPORTS MEDICINE DEPARTMENT Medical Care & Insurance Plan Document The Northwestern University Department of Athletics and Recreation (NUDAR) seeks to provide comprehensive athletic
More informationSports Medicine & Medical Insurance Policies. Samford University Department of Athletics
Sports Medicine & Medical Insurance Policies Samford University Department of Athletics Introduction: The Samford University Department of Athletics seeks to provide the highest quality health care to
More informationMISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE HEALTH INSURANCE INFORMATION SCHOLARSHIP AND WALK-ON STUDENT ATHLETES
MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE HEALTH INSURANCE INFORMATION SCHOLARSHIP AND WALK-ON STUDENT ATHLETES In the event that your son/daughter is injured while participating
More informationHow To Participate In A Varsity Sport At A College Football Program
Athletic Training MEMO: Athletic Participation TO: DATE: FROM: All Varsity Student-Athletes and Parents For the 2007-2008 Academic Year Michael DeSavage, Head Athletic Trainer NEW Athletes & TRANSFERS
More informationUniversity of New Orleans Department of Sports Medicine Medical Care, Insurance, and Payment Policies and Procedures
University of New Orleans Department of Sports Medicine Medical Care, Insurance, and Payment Policies and Procedures The University of New Orleans Department of Sports Medicine seeks to provide comprehensive
More informationDrug & Alcohol Education and Testing Program
Drug & Alcohol Education and Testing Program 1. Introduction The following policy statement has been adopted and shall be administered by the Huston- Tillotson University Athletic Department. Huston-Tillotson
More information2014/15 STUDENT-ATHLETE SPORTS PHYSICAL PACKET
2014/15 STUDENT-ATHLETE SPORTS PHYSICAL PACKET Athlete Information Form Please complete entire form Athlete Name: Athlete Cell: Sex: M F Age: Graduation Year: Sport(s): Allergies: Medications: Emergency
More information2013-2014 NCAA Year-Round Drug-Testing Site Coordinator Manual
2013-2014 NCAA Year-Round Drug-Testing Site Coordinator Manual NCAA Year-Round Drug-Testing Site Coordinator Manual Table of Contents Section 1 Introduction Page The National Center for Drug Free Sport
More informationAcademy of Art University Sports Medicine Returning Student-Athlete Physical Packet
Attention: Returning Student-Athletes Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet On Behalf of the Sports Medicine Department, we look forward to another healthy
More informationOhio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST
Ohio Valley University Athletic Department Medical Information & Health Insurance Information Packet READ OVER THIS ENTIRE CHECKLIST Page 2 (Physical Examination Form): Page two of this packet is the ONLY
More informationNo person under 21 years of age may use or be in possession of alcoholic beverages.
Student Drug and Alcohol Abuse Prevention Program Health Risks and Effects: Alcohol and drug usage causes a number of marked changes in behavior. Even low doses significantly impair the judgment and coordination
More informationCHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM
CHILDREN ON CAMPUS PARTICIPATION AGREEMENT AND WAIVER FORM PROGRAM/CAMP INFORMATION Parents and legal guardians are responsible for carefully reviewing all program materials and for selecting programs
More informationTexas Association of Private and Parochial Schools
Texas Association of Private and Parochial Schools P.O. Box 1039 601 N. Main Salado, Texas 76571 Date: April 1, 2014 254-947-9268 254-947-9368 (Fax) To: Head Administrators Athletic Directors Coaches Parents
More informationUALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian:
UALR Sports Medicine PLEASE READ AND FOLLOW ACCORDINGLY Dear Parent or Guardian: Enclosed is important information regarding athletic accident insurance that requires your immediate attention and response.
More informationChristian Brothers University Medical Certification for individual Student Athlete Participation: MUST EACH 1. pre participation physical: 2. 3. 4.
Christian Brothers University Medical Care and Insurance Procedures (Revised 12/8/14) Medical Certification for individual Student Athlete Participation: Christian Brothers University requires all student-athletes
More informationUniversity of West Florida Sports Medicine
University of West Florida Dear Argonaut, On behalf of the UWF Staff, I would like to welcome you to UWF and congratulate you on joining the UWF Athletic Department. I would like to take this time to inform
More informationUNIVERSITY OF CENTRAL FLORIDA SPORTS MEDICINE DEPARTMENT Medical Care & Insurance Procedures
UNIVERSITY OF CENTRAL FLORIDA SPORTS MEDICINE DEPARTMENT Medical Care & Insurance Procedures The University of Central Florida Athletic Association, Inc. (UCFAA) seeks to provide comprehensive athletic
More information***COPY OF FRONT AND BACK OF INSURANCE CARD***
We would like to take a moment to welcome you back for 2015-16 school year at the University of San Francisco. This packet is intended to introduce you to the Sports Medicine staff and to provide information
More informationUNIVERSITY OF TOLEDO SPORTS MEDICINE POLICIES AND PROCEDURES
1 UNIVERSITY OF TOLEDO SPORTS MEDICINE POLICIES AND PROCEDURES 1. Athletic Insurance Coverage. Revised 2009 Insurance coverage for any injury sustained while participating in an intercollegiate sport at
More informationUNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT
UNIVERSITY OF THE INCARNATE WORD SPORTS MEDICINE DEPARTMENT Release and Waiver of Liability, Assumption of Risk, Indemnity and Hold Harmless Agreements The signed student-athlete is enrolled at the University
More informationDRUG-TESTING PROGRAM
DRUG-TESTING PROGRAM 2015-16 Banned Drugs Stimulants Anabolic Agents Alcohol and Beta Blockers (banned for rifle only) Diuretics/Masking Agents Street Drugs Peptide Hormones and Analogues Anti-estrogens
More informationII. Returning student-athletes must update their information each year.
General Policies: The Alcorn State University Sports Medicine Program aims to provide prevention, treatment, and rehabilitation of athletic injuries and ensure the highest standard of medical care for
More informationDear Potomac State College Student Athletes and Parents:
Dear Potomac State College Student Athletes and Parents: We are please to have your son/daughter as a student athlete at Potomac State College of West Virginia University and hope that he/she will achieve
More informationStudent-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES)
Student-Athlete Insurance Information Form PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD (BOTH SIDES) PLEASE PRINT ALL INFORMATION CLEARLY AND COMPLETELY! Student-Athlete s Name: SS# - - DOB / /19 (mm/dd/year)
More informationBest Practices for Developing Drug-Testing Policies
Best Practices for Developing Drug-Testing Policies 2013 APPLE Conference Kathy J. Turpin, PhD Senior Director of Sport Drug Testing Our Clients 300+ individual college and university drugtesting programs
More informationStudent-Athlete Handbook
Student-Athlete Handbook This Student-Athlete Handbook belongs to: Name Sport As a student-athlete at Northwestern Oklahoma State University, you are responsible for the information in this handbook as
More informationIHSA Sports Medicine Acknowledgement & Consent Form. Concussion Information Sheet
Concussion Information Sheet A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force
More informationST. JOHN S STUDENT-ATHLETE SPORTS MEDICINE CHECKLIST 2015-2016
ST. JOHN S STUDENT-ATHLETE SPORTS MEDICINE CHECKLIST 2015-2016 Prior to participating with St. John s Athletics, you will receive several medical forms. Each form is important and must be completed prior
More informationATTENTION STUDENT-ATHLETE PARENT/GUARDIAN
ATTENTION STUDENT-ATHLETE PARENT/GUARDIAN All first-year and transfer students have two SEPARATE requirements: Requirement #1 is for ADMISSION to Shippensburg University (see checklist below). Requirement
More informationSubstance Abuse Policy and Procedure
ALABAMA A&M UNIVERSITY Substance Abuse Policy and Procedure AAMU Athletic Department January 2010 Table of Contents Introduction.. 3 Objectives. 4 Drug Education 4 Drug Testing Procedures... 5 Notification
More informationSports Medicine Policy and Procedures
Sports Medicine Policy and Procedures A. Introduction DEPARTMENT OF INTERCOLLEGIATE ATHLETICS Lourdes University Athletic Department strives to provide the highest quality of health care to each and every
More informationwww.goleathernecks.com
Dear Student-Athlete, Welcome back to Western Illinois University! The Sports Medicine Department provides comprehensive medical care for injuries and illnesses suffered while competing as a WIU student-athlete.
More informationAlabama A&M University Sports Medicine. Athletic Injury and Medical Policy
Alabama A&M University Sports Medicine Athletic Injury and Medical Policy General Policies: A comprehensive Sports Medicine Program of prevention, treatment, and rehabilitation has been developed to ensure
More informationAcknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
More informationName: Grade: Age: Answer the following questions as accurately as possible. (Explain yes answers below.) SINCE YOUR LAST PHYSICAL EXAMINATION: Yes No
TRUMANSBURG CENTRAL SCHOOL SPORTS CANDIDATE QUESTIONNAIRE This packet needs to be filled out within 30 days from the beginning of the season and turned into the nurse no later than 1 week prior to the
More informationCentral Michigan University Athletic Department Sports Medicine Services. Mission Statement. Section I Professional Medical Staff / Facilities
Central Michigan University Athletic Department Sports Medicine Services Mission Statement "Central Michigan University Athletic Department is committed to providing all student-athletes a level of care
More informationNAME: (PRINT) First Last. College M#:
SPORT (s): NAME: (PRINT) First Last College M#: MONTGOMERY COLLEGE SPORTS MEDICINE PACKET INSTRUCTIONS: - 7/11 - DO NOT remove any papers this includes the four physical exam pages! - If downloading from
More informationDrug-Testing Program 2013-14. www.ncaa.org/drugtesting
Drug-Testing Program 2013-14 www.ncaa.org/drugtesting Contents Page Chapter I. NCAA Banned-Drugs... 2 Chapter II. Medical Exceptions Process... 2 Chapter III. Alcohol, Tobacco and Other Drug-Education
More informationUniversity of Nebraska Omaha Policies and Procedures Regarding Insurance and Medical Expenses
University of Nebraska Omaha Policies and Procedures Regarding Insurance and Medical Expenses It is the policy of the UNO Athletic Department that all student-athletes be covered by a major medical health
More information2014-15 Point Park University Medical Packet CONTENTS
2014-15 Point Park University Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2014-15 year. Please return all completed forms
More informationIU Sports Medicine Information Sheet
IU Sports Medicine Information Sheet SPORTS MEDICINE PROGRAM A. MEDICAL SERVICES The sports medicine program at Indiana University works under the direct supervision of the team physician who is located
More informationUNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
More informationDr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
More informationLake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600
PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company
More informationSOUTHEASTERN OKLAHOMA STATE UNIVERSITY. ALCOHOL, TOBACCO, and OTHER DRUG-EDUCATION GUIDELINES. and the. DRUG-TESTING PROGRAM for STUDENT-ATHLETES
SOUTHEASTERN OKLAHOMA STATE UNIVERSITY ALCOHOL, TOBACCO, and OTHER DRUG-EDUCATION GUIDELINES and the DRUG-TESTING PROGRAM for STUDENT-ATHLETES Student-athletes are responsible for anything they ingest.
More informationPHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider
PHYSICAL EXAMINATION FORM (ATHLETE) To be filled out by Health Care Provider All full-time, undergraduate students must have a physical exam. PERSONAL DATA Name: Last First Middle Birthdate: Height: Weight:
More informationKU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION
KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance
More informationUNIVERSITY OF NEW HAVEN DEPARTMENT OF ATHLETICS Alcohol, Tobacco, and Other Drugs Substance Abuse Policy (ATOD)
UNIVERSITY OF NEW HAVEN DEPARTMENT OF ATHLETICS Alcohol, Tobacco, and Other Drugs Substance Abuse Policy (ATOD) The University of New Haven Department of Athletics substance abuse policy is founded in
More informationNORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a
More informationUNCG DEPARTMENT OF ATHLETICS DRUG INTERVENTION PROGRAM
UNCG DEPARTMENT OF ATHLETICS DRUG INTERVENTION PROGRAM The intent of this program is to prevent the use of prohibited substances by student-athletes through education, testing, and professional counseling.
More informationThe University of West Alabama
The University of West Alabama 2014-2015 Student Athlete Handbook Dear UWA Student-Athlete, The University of West Alabama has an outstanding and proud tradition of academic and athletic excellence. We
More informationDavidson College Sports Medicine Football New Athlete Pre-Participation Letter
Davidson College Sports Medicine Football New Athlete Pre-Participation Letter The Davidson College Sports Medicine Staff would like to welcome you to Davidson College. We look forward to working with
More information2015-16 Point Park University Athletics Medical Packet CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!
2015-16 Point Park University Athletics Medical Packet Enclosed you will find many of the necessary forms needed to compete in intercollegiate athletics during the 2015-16 year. Please return all completed
More informationEAST CAROLINA UNIVERSITY DRUG EDUCATION SCREENING COUNSELING AND TESTING PROGRAM POLICY
EAST CAROLINA UNIVERSITY DRUG EDUCATION SCREENING COUNSELING AND TESTING PROGRAM POLICY A. Introduction: The improper use of drugs has become a matter of deep concern within our society. Many lives are
More informationAGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
More informationGEORGE MASON UNIVERSITY. Intercollegiate Athletics Drug and Alcohol Education and Testing Program POLICY
GEORGE MASON UNIVERSITY Intercollegiate Athletics Drug and Alcohol Education and Testing Program POLICY I. PURPOSE The Department of Intercollegiate Athletics at George Mason University (GMU) is concerned
More informationFURMAN UNIVERSITY SPORTSMEDICINE CENTER
FURMAN UNIVERSITY SPORTSMEDICINE CENTER Dear Student-Athlete: The Furman University Athletic Department recognizes that the use of abusive drugs and alcohol is a major problem facing society today. The
More information5/17/2012 11:09:04 AM
DEPARTMENT OF INTERCOLLEGIATE ATHLETICS SUBSTANCE ABUSE POLICY A. PURPOSE The Louisiana Tech University Athletic Department ( LA Tech ) has established the Athletic Department Assistance Program ( ADAP
More informationMalone University Athletics Institutional Drug Education and Testing Policy
Malone University Athletics Institutional Drug Education and Testing Policy Note: This policy referenced from Michigan State University's Student-Athlete Drug Education and Testing Policy with permission
More informationLEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP. TODAYS DATE:, 20 Sport:
LEES-MCRAE COLLEGE HISTORY FOR ANNUAL CHECK-UP Pages 1 & 2 are to be completed by the student-athlete and/or his/her parent/guardian and taken along with page 3 to physician or health care professional
More informationWEBER STATE UNIVERSITY SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS DRUG ABUSE PROGRAM
WEBER STATE UNIVERSITY SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS DRUG ABUSE PROGRAM The department of intercollegiate athletics at Weber State University its coaching personnel and administrators, strongly
More informationDRUG-TESTING PROGRAM 2016-17
DRUG-TESTING PROGRAM 2016-17 Banned Drugs Stimulants Anabolic Agents Alcohol and Beta Blockers (banned for rifle only) Diuretics/Masking Agents Street/Illicit Drugs Peptide Hormones and Analogues Anti-estrogens
More informationMountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION
Mountain View Natural Medicine Lorilee Schoenbeck ND, PC Jessica Stadtmauer ND Dana Dabransky ND Sara Norris ND 185 Tilley Dr. Suite 51 S. Burlington, VT 05403 Phone: (802) 860-3366 Fax: (866) 440-8220
More informationLane College. Department of Intercollegiate Athletics. Lane College Athletic Drug/Alcohol Education and Testing Program Policy
Lane College Department of Intercollegiate Athletics Lane College Athletic Drug/Alcohol Education and Testing Program Policy I. Introduction: The Department of Intercollegiate Athletics at Lane College
More informationFIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
More informationATHLETIC PARTICIPATION MEDICAL PACKET (SOPHOMORES)
ATHLETIC PARTICIPATION MEDICAL PACKET (SOPHOMORES) Dear Weatherford College Athlete, Athletic Training & Sports Medicine A new year of Weatherford College Athletics is quickly approaching. I hope this
More informationMEDICAL AND INSURANCE POLICIES & PROCEDURES Sports Medicine services are available to all student-athletes. Each intercollegiate athletic team has an
MEDICAL AND INSURANCE POLICIES & PROCEDURES Sports Medicine services are available to all student-athletes. Each intercollegiate athletic team has an assigned certified athletic trainer, but any of the
More informationTHE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please
More informationBOSTON UNIVERSITY DEPARTMENT OF ATHLETICS DRUG TESTING AND EDUCATION POLICY
BOSTON UNIVERSITY DEPARTMENT OF ATHLETICS DRUG TESTING AND EDUCATION POLICY Boston University supports the National Collegiate Athletics Association s policy regarding alcohol abuse and the use of banned
More informationThe following is a checklist, for your personal use, of all the forms that must be returned to Manhattanville College Sports Medicine by August 1:
Dear new student athlete: The Sports Medicine Staff would like to take this opportunity to welcome you to Manhattanville College. We work to provide all student athletes with comprehensive health care
More informationPatient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
More informationWorkman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
More informationPre-Participation Physical Evaluation
1 Dear Returning YHC Student-Athlete and Parents/Guardians, As a Young Harris College student-athlete, we certainly hope that medical treatment for a serious injury is not necessary, but in the event that
More information