Portland State University Sports Medicine Returning Student Athlete Health Report Form

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1 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 completed before you resume official workouts with your team. The NCAA does not require documentation of an annual physical to continue playing intercollegiate athletics, so long as the following questionnaire is completed, and check in with ATC is completed. The Portland State Sports Medicine Department strongly encourages student athletes to have annual physical performed by their PCP. A follow up with a doctor may be deemed necessary prior to workouts, and will be determined by the Sports Medicine Staff. NOTE TO STUDENTS: It is vital that the Sports Medicine Department receives an accurate health history, an appropriate sports physical, and results of a sickle cell test. We ask for your understanding with our strict requirements as all play an important role in identifying individuals who may be at risk for sudden death during athletics. For more information please contact one of the staff athletic trainers. Returning Student Athlete Checklist: o Sports Medicine Medical Questionnaire Update o Student Athlete Assumption of Risk and Consent for Treatment o Chemical Consent and Release Form o Concussion Waiver o Release of Protected Health Information o Insurance and policy holder information. IF INSURANCE HAS CHANGED (Separate Form) o ADD/ADHD forms signed by physician IF NECESSARY (Separate Form) The completion of the above checklist does not guarantee clearance for participation in intercollegiate athletics at Portland State If you have had an injury in the past twelve months that has removed you from participation for any length of time, you must submit written documentation of clearance for intercollegiate athletic participation from the physician who is, or has managed, your injury. If you have an ongoing medical condition (i.e. seizure disorder, heart murmur, sickle cell, cardiac conditions) you must submit documentation that you are cleared to participate in intercollegiate athletic activity. The Portland State Sports Medicine Department s athletic trainers and team physician have the final decision regarding clearance for participation in intercollegiate athletics.

2 Pre participation Questionnaire Demographic Information Last Name: First Name: Middle Initial: of Birth: Biological Sex: M F Sports: Year of PSU Graduation: PSU Address: (City, St, Zip) Emergency Contact Name: Relationship to student: Emergency Contact Information: Cell Phone Number: ( ) Class Standing for Sport: Student Contact Information: Cell phone: ( ) Address: Emergency Contact Name: Relationship to student: Emergency Contact Information: Cell Phone Number: ( ) Medicines: Please list all prescription and over the counter medications that you are currently taking. (Including birth control, insulin, inhalers, supplements etc.) Please indicate name, does, purpose, and frequency of use. General Medical History From the Past 12 Months Yes No 1. Are you currently being treated for an athletic injury sustained this past season? 2. Do you have any ongoing medical conditions not athletically related? 3. Did you for any reason visit the hospital in the past 12 months? 4. Have you had a general physical in the past 12 months? 5. Would you like to speak with a member of the sports medicine staff for any reason? 6. Had a severe viral infection (mononucleosis)? 7. Had a seizure? 8. Had trouble breathing or been diagnosed with asthma? 9. Had a physician deny or restrict your participation in sports for any reason? If you answered yes to any of the above questions please provide further information including specific condition, date of diagnosis or treatment, and duration of injury or condition. Heart Health Questions About you (In the past 12 months) Yes No 10. Have you ever passed out or nearly passed out DURING or AFTER exercise?

3 11. Have you ever had discomfort, pain tightness, or pressure in your chest during exercise? 12. Does your heart ever race or skip beats (irregular beats) during exercise? 13. Has a doctor ever told you that you have any heart problems? Or restrict you for any of the following? Including but not limited to high blood pressure, high cholesterol, heart murmur, heart infection, rheumatic fever, Kawasaki disease, or any other heart or vascular problems? 14. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram) 15. Do you get lightheaded or feel more short of breath than expected during exercise? 16. Have you ever had an unexplained seizure? 17. Do you get more tired or short of breath more quickly than your friends during exercise? 18. Had a family member/relative die of a heart problem or sudden death before age 50? If you answered yes to any of the above questions please explain in the space below: Eye Health History Yes No 19. Do you wear glasses or contact lenses? 20. Do you have an eye condition that is not correctable by glasses or contacts? 21. Are you legally blind in either of your eyes? 22. Has it been more than a year since your last eye exam? If you answered yes to any of the above questions please provide further information. Dental Health History Yes No 23. Do you wear any of the following dental appliances: permanent bridge, full plate, permanent crown, braces, or any other appliance? 24. Do you have any dead teeth? 25. Have you ever suffered from or are you currently suffering from Temporal Mandibular Joint Syndrome If you answered yes to any of the above questions please provide further information. Head injury and concussion history (in the past 12 months) Yes No 26. Did you suffer a head injury or concussion with or without loss of consciousness? 27. Did you get knocked unconscious? 28. If yes, did you report your injury to the Sports Medicine staff? If you answered yes to any of the above questions please explain in the space below:

4 Student Athlete Acknowledgement Assumption of Risk And Consent for Treatment: By its nature, I understand that participation in Intercollegiate Athletics involves a risk of injury which may range in severity from minor to catastrophic, including, but not limited to, permanent paralysis, bone or joint injury, other chronic disabling conditions and even death. Although serious injuries are not common in supervised intercollegiate athletic activities, it is possible only to minimize, not eliminate the risk. I understand that participants can and have the responsibility to help reduce the chance of injury. I know that I must obey all safety rules, report all athletic injuries to the athletic trainers or medical staff, follow a proper conditioning program and inspect all equipment daily. I hereby accept and assume the risk of injury and understand the possible consequences of such injury. I recognize that it is my responsibility to report all injures that I have experienced. Reporting past conditions is part of my responsibility as a student athlete to assist in the evaluation of my ability to participate. Accurate information is very important in the management of my physical conditioning, care and prevention of injuries that may occur as a result of my athletic participation. Therefore, I hereby state that, to the best of my knowledge, my answers to the Pre Participation Questionnaire are correct. I consent to treatment by Portland State University Sports Medicine staff while I am enrolled at Portland State University. I understand that there is no charge to be examined by a provider within the Sports Medicine Department. However, I also understand that I and/or my insurance plan may incur charges for additional medical services including (but not limited to) lab tests, radiology tests, prescription medications, durable medical equipment, and ambulance transportation. Student-Athlete Signature Parent/Guardian if athlete is under 18 Sport PSU ID# Peter W. Stott Center * 930 SW Hall St * Portland, OR Ph:(503) Fax: (503)

5 Examination By ATC or Team Physician- (Vision check is only needed if deemed necessary) Height: Weight: Male Female BP / Pulse Vision R 20/ L 20/ Corrected: Yes No Clearance Check one Box Comments Cleared for all sports without restriction. Cleared for all sports without restriction with recommendations for further evaluation or treatment. Not Cleared. (Pending further evaluation, for any sports, or certain sports) Further Recommendations Name of ATC or Physician (print) Signature City/State of Practice Phone_

6 Portland State University Sports Medicine Student Athlete Chemical Consent and Release Form Chemical Health Release Authorization I, have had an opportunity to thoroughly examine Portland State University s Chemical Health Program for Intercollegiate Athletics. I have also had an opportunity to ask any questions I might have regarding any aspects of this document answered by appropriate University Officials. I,, agree to abide to all provisions of the PSU Chemical Health Program. I understand that prohibited drug use may result in restricted intercollegiate participation, or in the case of repeated use, expulsion from the team or sport and loss of athletic grant-in-aid assistance. Further, I agree to hold harmless any and all individuals who may be involved in the implementation of this Chemical Health Program as long as such individuals acted in good faith. Although I understand that diligent efforts will be made to keep all information generated on a particular student-athlete involved in the program confidential, I do authorize the release of such information or documentation to any individual who the University Team Physician(s) believe(s) have a legitimate need to review such material. Student-Athlete Signature Parent/Guardian if athlete is under 18 Sport PSU ID# Peter W. Stott Center * 930 SW Hall St * Portland, OR Ph:(503) Fax: (503) NCAA Banned Substance List I, have had an opportunity to thoroughly examine the NCAA Banned Drugs List, bylaw , which was copied from the NCAA Sports Medicine Handbook. I have also had an opportunity to ask any questions I might have regarding any aspect of this document answered by appropriate University Officials. Student-Athlete Signature Sport PSU ID# Peter W. Stott Center * 930 SW Hall St * Portland, OR Ph:(503) Fax: (503)

7 Portland State University Sports Medicine Concussion Waiver I, (Print Name) do hereby affirm that I have been informed by Portland State University Sports Medicine Staff on () about PSU s concussion policy and have been presented with educational material on concussions. The signs, symptoms, and/or behaviors of a concussion may include any combination of the following (as established by SCAT 3 concussion screening tool, part of the Zurich concussion guidelines): Headache, pressure in head, neck pain, balance problems or dizziness, nausea or vomiting, vision problems, hearing problems/ringing, don't feel right, feeling dinged or dazed, confusion, feeling slowed down, feeling in a fog, drowsiness, fatigue or low energy, more emotional than usual, irritable, difficulty concentrating, difficulty remembering, sadness, nervous or anxious, trouble falling asleep, sleeping more than usual, sensitivity to light, and sensitivity to noise. (Initial) I accept responsibility for reporting any and all injuries to a member of the Portland State University Sports Medicine staff, and coaching staff including signs and symptoms of concussions. (Initial) I understand that should I exhibit signs, symptoms or behaviors consistent with a concussion I will be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. (Initial) I understand that medical clearance will be determined by the team physician, or their designee according to the concussion management plan. Student-Athlete Signature Parent/Guardian if athlete is under 18 Sport PSU ID# Peter W. Stott Center * 930 SW Hall St * Portland, OR Ph:(503) Fax: (503)

8 Portland State University Sports Medicine Release of protected health information I authorize Portland State University (PSU) and its physicians, athletic trainers, and health care personnel, at their discretion, to use and disclose a copy of the specific health information described below regarding: (Name of student athlete) consisting of protected health information and any related information regarding any injury or illness during my training or participation in intercollegiate athletics to the National Collegiate Athletic Association (NCAA), the Big Sky Conference, PSU, and PSU s employees or agents as well as my parents or legal guardians for the purpose of: Determining eligibility to participate in PSU athletics or changes in ability to participate in PSU athletics, including changes resulting from any injury or illness occurring during practice or competition Facilitating communication between physicians, athletic trainers, and coaches that would assist in the evaluation, diagnosis, or treatment of an injury or illness or Allowing safe participation in PSU athletics, including practice or competition, in light of know injury or illness If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information. HIV/AIDS Mental Health Genetic testing Drug/Alcohol diagnosis, treatment, or referral I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information. I understand that the NCAA, the Big Sky Conference, and media outlets are not covered by either HIPPA or FERPA and that these laws will not apply to their use or disclosure of my health information. PROVIDER INFORMATION You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. To revoke this authorization, please send a written statement to Jim Wallis (contact person) at P.O. Box 751, Portland, OR (address of person/entity disclosing information) and state that you are revoking this authorization. SIGNATURE I have read this authorization and I understand it. Unless revoked, this authorization expires when I am no longer a student athlete at PSU. By DOB - - PSU ID # (Individual or personal representative) Description of personal representative s authority:

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