Miami University Try Out Informational Packet

Transcription

1 Miami University Try Out Informational Packet Contents: A. Pre-Participation Physical (to be obtained and completed by a Physician at Student Health Services or licensed physician) B. Copy of Insurance Card C. Health History Form D. Family History Form E. Health Appraisal F. Assumption of Risk and Release of Liability Form G. Student-Athlete Declaration of Medical Condition Acknowledgement Form. H. Sickle Cell Waiver Form The Miami University Athletic Department will not be responsible for the expense of the physical by a licensed Physician. All forms must be completed, reviewed, accepted and on file with the Miami Sports Medicine Department 3 days prior to the tryout. Failure to complete these tasks will result in not being able to participate in the tryout. If you have any further questions please contact: Drew Ruckelshaus

2 MIAMI UNIVERSITY DEPARTMENT OF INTERCOLLEGIATE ATHLETES SPORTS MEDICINE HEALTH HISTORY NAME (PLEASE PRINT) SPORT DATE Please answer each of the following questions by placing an (X) in the YES blank at the right if your answer to the questions is YES, or by placing and (X) in the NO blank at the right if your answer to the questions is NO. If you are unable to answer for any reason, place a sold circle ( ) in the YES blank. PLEASE COMMENT SPECIFICALLY ON ANY YES ANSWERS IN THE SPACES ON THE LAST WHITE PAGE. NUMBER QUESTION NUMBER YES NO 1. Has a physician ever denied or restricted your participation in sports for any reason? Do you have any ongoing medical conditions (like diabetes or asthma)? Please list Are you currently taking any prescriptive or non prescriptive (over the counter) medications or pills? Please List Do you have allergies to medicines, pollens, foods or stinging insects? Please list Do you think you are in good health? Have you passed out or nearly passed out DURING exercise? Have you passed out or nearly passed out AFTER exercise? Have you ever had discomfort, pain or pressure in your chest during exercise? Does your heart race or skip beats during exercise Has a doctor ever told you that you have high blood pressure, high cholesterol, heart murmur, and/or heart infection? Please list Has a doctor ever ordered a test for your heart? (Ex. ECG, EKG, echocardiogram, etc.) Please list Has anyone in your family died for no apparent reason? Does anyone in your family have a heart problem? Has any family member died of heart problems or of sudden death before age 50? Does anyone in your family have Marfan Syndrome? Have you ever spent the night in a hospital? Have you ever had surgery? Has a doctor ever told you that you have asthma or allergies? Do you cough, wheeze, or have difficulty breathing during or after exercise? Is there anyone in your family who has asthma? Have you ever used an inhaler or taken asthma medication? Were you born without or are you missing a kidney, an eye, testicle, or any other organ? Have you had infectious mononucleosis (mono) within in the last 6 months? Do you have rashes, pressure sores, or other skin problems? Have you had a herpes skin infection? Have you ever had a head injury or concussion? Have you been hit in the head and been confused or lost your memory? Have you ever had a seizure? Do you have headaches with exercise? Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? When exercising in the heat, do you have severe muscle cramps or become ill? Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? Have you had any problems with your eyes or vision? Do you wear glasses or contact lenses? Do you wear protective eyewear, such as goggles or a face shield? Please list Are you happy with your weight? Are you trying to gain or lose weight? Has anyone recommended that you change your weight or eating habits? Do you limit or carefully control what you eat? Do you have difficulty hearing? Have you had a history of earaches? Do you have a repeated buzzing or noises in your ears? Do you get motion sickness riding in a car, plane, or bus? Have you had burning or pains when you urinate? Has your urine ever been brown, black or bloody? Have you ever had a stress fracture? Have you been told that you have or have you had any x-ray for atlantoaxial (neck) instability? Do you regularly use a brace or assistive device? Please list Have you ever had any type head injury that required a surgical intervention or plate? Have you ever had hospitalization, surgery, injury or serious medical illness? 50.

3 51. Orthopedic Questions Please check all injuries that apply and explain the additional questions appropriately: Injury Date Occurred DIAGNOSIS DIAGNOSTIC TESTIING REHAB: TIME MISSED: Has injury caused Examples: Examples: Examples: Examples: recurrent pain? Strain, sprain, etc. MRI, X-ray, CT, etc.) PT, OT, ATC Practice, games, days, weeks, months. Please list. Please answer: Yes or No Head Unconscious Shoulder Neck Back Ribs Hips Lower Leg Thigh Knee Ankle Foot Elbow COMMENTS: Hand/Wrist I (we) hereby state, to the best of my (our) knowledge, my (our) answers to the above questions are complete and correct. Signature: Student Athlete Signature: Parent or Guardian (if athlete is under 18) Date: Date: G:\Users\JOLIVESW\1 GROSS CENTER\SPORTS MEDICINE\MEDICAL FORMS ALL STUDENT ATHLETES\9 HEALTH HISTORY FORM JEN'S UPDATED COPY.doc THIS WILL NOT APPEAR ON THE DOCUMENT WHEN PRINTED FOR STUDENTS.

4 MIAMI UNIVERSITY SPORTS MEDICINE FAMILY HISTORY Athlete: Sport: Date: FAMILY HISTORY: For your family members below, follow the line across the page and mark an X in those boxes which indicate their present state of health (good or poor), or their death (state cause), and any illness that they ever had. Please print the names of your relatives living or dead in the appropriate row. Name In Good Health In Poor Health Date of Death Cause of Death Your Health Father Mother Brother(s) Sister(s) Spouse Children Allergies or Asthma Anemia or Sickle Cell Bleeding tendencies Diabetes / Gout Cancer or Tumor Epilepsy Yellow Jaundice Missing any Paired Organs High Blood Pressure Kidney or Bladder Trouble Ulcer Rheumatic Fever Rheumatism or Arthritis Heart Trouble Additional Remarks: EYE AND DENTAL HEALTH: 1. Do you wear eye glasses or contacts?

5 2. If answer to above is yes, do you wear them during athletic participation? 3. Do you wear any dental appliance? If Yes, check the appropriate appliance: Permanent bridge Removable Partial Permanent crown or jacket Full Plate 4. Do you have any dead teeth? Please indicate approximate location of dead tooth or teeth: MAJOR HOSPITALIZATIONS: Write in your most recent hospitalizations below (noting most recent in the top row). Year Operation or Illness Name of Hospital City and State Additional Hospitalizations: MEDICINES: List any medicines that you are currently taking: List any medicines that you are allergic to: FOR WOMEN ONLY: MENSTRUAL HISTORY Age of onset: Pain or cramps? Regular? Date of last period: Cycle? days Lumps in breast? Usual duration? days Number of periods in the last year: Heavy Medium Light TO THE BEST OF MY KNOWLEDGE THE ABOVE STATEMENTS ARE TRUE. Athlete Signature:

6 MIAMI UNIVERSITY SPORTS MEDICINE HEALTH APPRAISAL Athlete: Sport: Date: Birthdate: Sex: SSN: Street City State Local Address: Local Phone: Parent(s) Name: Street City State Parent(s) Address: Parent(s) Home Phone: Parent(s) Work Phone: ATHLETE'S HISTORY: 1.Have you had a complete physical examination within the last four years? 2.If yes, did the examination disclose any health problems, or result in any recommendation that you should limit your activities? 3.Since your last physical examination, have you suffered any INJURY, MEDICAL ILLNESS, or HAD ANY SURGERY? 4.Are you now under the care of a physician or taking any medication? 5.Do you feel that there are any limitations placed on your full participation? 6.Do you have any allergies? Medications: Other: 7.Do you wear glasses or contact lenses? Date of last eye exam: 8.Have you ever been advised not to participate in any form of organized athletics? 9.Have you ever received organized coaching in the sport you are trying out for at least one full season? For how many years? 10.Are you currently taking oral contraceptives? If yes, these may alter your lab results. Please let the nurse know during your physical. If you answered "Yes" to any of the above, please explain: MEDICAL INFORMATION RELEASE AUTHORIZATION I authorize the University's Doctors and Athletic Trainers to release any and all medical information concerning any and all injuries and/or illnesses that have occurred to me while participating for athletic teams for Miami University. To the best of my knowledge, the preceding information is correct and up to date. I have not willingly or knowingly withheld medical information that would affect my eligibility to participate in athletics at Miami University. Athlete Signature: Athlete Signature: Date: Date:

7 MIAMI UNIVERSITY ASSUMPTION OF RISK AND RELEASE OF LIABILITY FORM I understand that Miami University ( Miami ) is permitting me to try-out for participation with Miami University (Sport/Activity) (for this form, the term Activity shall also include all travel to and from the Activity). In consideration for being allowed to participate in the Activity, I knowingly and voluntarily: acknowledge and understand that my participation in the Activity is entirely voluntary; acknowledge that the Activity involves significant physical activity and that there are risks and hazards which may arise from participation in this Activity acknowledge that my participation in the Activity may result in injury (serious and minor), loss of life, and/or loss of property; represent that I have had the opportunity to ask any questions that I have about the Activity; represent that I am physically and psychologically healthy enough to participate in the Activity; acknowledge that any Miami personnel or agents attending the Activity are not necessarily medically trained to care for any physical or medical problems of individuals participating in the Activity; represent that I am financially responsible for any injuries that I may receive as a result of my participation in the Activity, and that I have adequate health and hospitalization insurance to cover such financial responsibility; and agree to follow all the safety rules, procedures and instructions of Miami and the Activity leaders (e.g., appropriate dress, proper use of safety equipment, etc.) and to avoid unnecessary hazardous situations, whether or not those situations have been specified. On behalf of myself and my heirs and assigns, I knowingly and voluntarily assume all risks associated with the Activity and release Miami, its trustees, officers, employees and agents (collectively Miami Parties ) from any and all responsibility or liability for personal injury, emotional injury, death or property damage sustained by me during or because of my participation in the Activity. I agree, for myself, my administrators, personal representatives, executors, predecessors, successors, agents, heirs and assigns to release and hold harmless the Miami Parties from any present or future claim for personal injury, emotional injury, death or property damage arising directly or indirectly from my participation in the Activity, to the fullest extent permitted under law, including allegations or claims of negligence on the part of the Miami Parties, provided, however, this form does not apply to acts of gross negligence, willful or wanton conduct, or intentional conduct. I UNDERSTAND AND AGREE THAT BY SIGNING THIS FORM I WILL WAIVE AND FOREVER RELINQUISH ANY AND ALL CLAIMS THAT I MAY HAVE, WHETHER KNOWN OR UNKNOWN, AND WHETHER ANTICIPATED OR UNANTICIPATED, AGAINST THE MAIMI PARTIES ARISING OUT OF MY PARTICIPATION IN THE ACTIVITY. Signature: Date: Name (Printed): Telephone: PARTICIPANTS UNDER THE AGE OF 18 MUST HAVE A PARENTAL OR GUARDIAN COUNTERSIGNATURE I understand and agree that if I am signing this form on behalf of my minor child, that: (i) I will be giving up the same rights for the minor as I would be giving up if I signed this document on my own behalf, and (ii) I personally represent and warrant that I am authorized to sign the form on behalf of the minor. Parental/Guardian Signature Parental/Guardian Name - Printed

8 Miami University Sports Medicine Student-Athlete Declaration of Medical Condition Acknowledgement I, [NAME OF STUDENT ATHLETE], am aware that participation as a student-athlete in [SPORT] puts me at risk for serious injuries and/or medical conditions. I understand that sharing information with Miami University s medical staff is important to helping maintain my safety, and I agree to the following instructions: Before I start practice, I will inform the Miami University Sports Medicine Department about any injury, orthopedic issue, and/or general medical condition in order to receive appropriate medical attention. In the event that I develop any injury, orthopedic issue and/or general medical condition during my sports season, I will immediately inform the Miami University Sports Medicine Department in order to receive appropriate medical attention. I will be responsible for disclosing any injury, orthopedic issue and/or general medical condition during my Exit Physical Examination which I must schedule with Miami University Sports Medicine before the end of the academic year and/or athletic competitive season (whichever is later) in which I have exhausted my athletic eligibility or opted to discontinue participation in intervarsity athletics (whichever is sooner). I understand that if I fail to disclose any known or suspected injury, orthopedic issue and/or general medical condition to the Miami University Sports Medicine Department and seek medical treatment then I release Miami University from any and all responsibility and liability for such injuries/medical condition(s). Signature of Student-Athlete: Date: Signature of Parent or Guardian: Date: (If Student-Athlete is 18 years of age or younger both the Student and the Parent/Guardian must sign) IF YOU HAVE QUESTIONS, PLEASE CONTACT MIAMI UNIVERSITY SPORTS MEDICINE DEPARTMENT AT: Miami University Sports Medicine Department 144 Yager Stadium Oxford, OH

9 Miami University- Department of Intercollegiate Athletics Sickle Cell Trait Testing Information and Waiver Form Student Athlete Name: Last First MI Banner ID #: Date of birth: / / Sickle Cell Trait Testing: Sickle Cell trait testing involves a simple blood test. People at higher risk for having the sickle cell trait are those of African, South or Central American, Caribbean, Mediterranean, Indian or Saudi Arabian descent. About 8% of the African-American population has the sickle cell trait. Sickle cell trait does not mean you have sickle cell anemia and does not prohibit participation in athletics or affect athletic performance. It does, however, place the student-athlete at higher risk for gross hematuria (blood in the urine), splenic infarction (chest pain with nausea and vomiting) and exertional rhabdomyolysis (which can be fatal and is exacerbated by dehydration). Exertional rhabdomyolysis has been linked to sudden death during basic training for the U.S. Armed Forces and the sudden death of student-athletes. The NCAA requires that all student-athletes provide proof of testing for the trait, be tested for the trait during the mandatory medical examination or sign a written release. The NCAA provides educational information regarding sickle cell trait testing which can be found at NCAA. Org ( Landing+Page). Miami University encourages testing and encourages student athletes to consult with family members, including parents and guardians, before making this decision. Informed Consent for Sickle Cell Trait Testing I consent to have my blood drawn by the Miami University Student Health Center for the purpose of sickle cell trait testing. I understand that the results of the test will be shared with the Department of Intercollegiate Athletics, including the Miami University Sports Medicine, Strength and Conditioning, and coaching staff. Signature Date Print Name Signature of Parent if under age 18 Date

10 Prior Testing Within Six Months: I have been tested for the sickle cell trait (had a sickle cell solubility test) within the previous six months and have attached the documentation of the results of the prior test. I understand that the results of the test will be shared with the Department of Intercollegiate Athletics, including the Miami University Sports Medicine, Strength and Conditioning, and coaching staff. Signature Date Print Name Decline Testing- Waiver of Liability: I have received and read the information pertaining to sickle cell trait testing. I acknowledge and understand the risks involved including the risk of sudden death. I decline to receive the sickle cell trait testing. On behalf of myself and my heirs and assigns, I knowingly and voluntarily assume all risks associated with the decision not to be tested and release the University, its trustees, officers, employees and agents from any and all responsibility or liability for personal injury, trauma or death sustained by me during or because of my decision not to be tested or because I have the sickle cell trait. I UNDERSTAND AND AGREE THAT BY SIGNING THIS FORM, I WAIVE AND FOREVER RELINQUISH ANY AND ALL CLAIMS THAT I MAY HAVE IN THE FUTURE, WHETHER KNOWN OR UNKNOWN, AND WHETHER ANTICIPATED OR UNANTICIPATED, ARISING OUT OF MY PARTICIPATION IN THE Intercollegiate Athletic Program as a result of my decision not to be tested or because I have the sickle cell trait. I understand and agree that if I am signing this form on behalf of my minor child, that I will be giving up the same rights for the minor (if student athlete is under 18 years of age) as I would be giving up if I signed this document on my own behalf. Signature: Date: Name (Printed): Parental Co-Signature (if under 18):

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