Medical History and Technical Standards Form

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1 Physical Examinations Effective with the UWF Catalog, any student applying to enter the Athletic Training Education Program must complete a comprehensive physical examination by a licensed physician. Students who are currently in the program and/or are classified under a previous academic year catalog are not required (but highly recommended) to complete a physical examination. Each student must assume the costs associated with the initial physical examination prior to admission. The physical examination may be obtained by the UWF Student Health Services, local physician, or the student s primary care physician. Effective with the application process for entry into the Athletic Training Education Program for the academic year, each student must read and sign the Technical Standards for Athletic Training Students document that will be included with the physical examination and medical history forms that follow. Physical Activity Definition Physical Activity (Preferred Usage) Physical activity consists of athletic, recreational or occupational activities that require physical skills and utilize strength, power, endurance, speed, flexibility, range of motion or agility. Physically Active Physically active individuals engage in athletic, recreational or occupational activities that require physical skills and utilize strength, power, endurance, speed, flexibility, range of motion or agility.

2 MEDICAL HISTORY FORM THIS INFORMATION IS FOR OFFICIAL AND MEDICALLY-CONFIDENTIAL USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS Name: Sport: Have you ever (Check each item. If yes, please explain) YES NO Explanation of Yes Responses: Lived with anyone with tuberculosis Coughed up blood Used tobacco products Worn a brace or back support Do you (Check each item. If yes, please explain) YES NO Explanation of Yes Responses: Wear a hearing aid Wear glasses/contact lenses Take any medications Have any allergies Have you ever had or do you have now (please check at left of each item) YES NO YES NO YES NO Swollen or painful joints Chronic cough Gastrointestinal trouble Frequent or severe headache Palpitation or pounding heart Gallstones/gall bladder trouble Dizziness or fainting spells Leg cramps Motion sickness Eye trouble Paralysis Depression or excessive worry Ear, nose, or throat trouble Epilepsy or convulsions Loss of memory Hearing loss Jaundice or hepatitis Periods of unconsciousness Chronic or frequent colds Frequent trouble sleeping Dental problems Sinusitis Tumor, growth, cyst, cancer Diabetes Hay Fever Hernia Organs missing Head Injury Hemorrhoids Heat exhaustion/stroke Skin disease Frequent or painful urination Arthritis or Rheumatism Thyroid trouble Kidney stone or blood in urine Female disorders Tuberculosis Recent gain or loss of weight Changes in menstrual pattern Asthma Heart trouble Frequent indigestion Shortness of breath High or low blood pressure Pain or pressure in chest

3 Have you ever (Check each item. If yes, please explain.) YES NO Does your family have a history of: YES NO 1. been withheld from physical activity because of injury or illness? 2. had or been advised to have an operation? 3. been a patient in a hospital? 4. consulted or been treated by clinics, physicians, healers, or other practicioners within the past five years for other than minor illness? 5. suffered a head or neck injury? 6. suffered from a shoulder, elbow, wrist, or hand injury? 7. suffered from a hip, knee, ankle, or foot injury? 8. had an injury other than those already noted? Diabetes High blood pressure Heart attacks or strokes Cancer Explanation of Yes Responses: If yes, what relation? I certify that I have reviewed the above information and that it is true and complete to the best of my knowledge. I understand that the results of the physical examination does not guarantee admission into this Athletic Training Education Program. Signature of Student Printed Name Date

4 TECHNICAL STANDARDS FOR ADMISSION The Athletic Training Education Program at the University of West Florida is a rigorous and intense program that places specific requirements and demands on the students enrolled in the program. An objective of this program is to prepare graduates to enter a variety of employment settings and to render care to a wide spectrum of individuals engaged in physical activity. The technical standards set forth by the Athletic Training Education Program establish the essential qualities considered necessary for students admitted to this program to achieve the knowledge, skills, and competencies of an entry-level athletic trainer, as well as fulfill certain standards and guidelines set forth by the Commission on Accreditation of Allied Health Education Programs [CAAHEP] for this program to achieve accreditation as an undergraduate athletic training education program. The following abilities and expectations must be met by all students admitted to the Athletic Training Education Program. In the event a student is unable to fulfill these technical standards, with or without reasonable accommodation, the student will not be admitted into the program. Compliance with the program s technical standards does not guarantee a student s eligibility for the NATABOC certification exam. Candidates for selection to the Athletic Training Education Program must demonstrate: 1. the mental capacity to assimilate, analyze, synthesize, integrate concepts and problem solve to formulate assessment and therapeutic judgments and to be able to distinguish deviations from the norm. 2. sufficient postural and neuromuscular control, sensory function, and coordination to perform appropriate physical examinations using accepted techniques; and accurately, safely and efficiently use equipment and materials during the assessment and treatment of patients. 3. the ability to communicate effectively and sensitively with patients and colleagues, including individuals from different cultural and social backgrounds; this includes, but is not limited to, the ability to establish rapport with patients and communicate judgments and treatment information effectively. Students must be able to understand and speak the English language at a level consistent with competent professional practice. 4. the ability to record the physical examination results and a treatment plan clearly and accurately. 5. the capacity to maintain composure and continue to function well during periods of high stress. 6. the perseverance, diligence and commitment to complete the athletic training education program as outlined and sequenced. 7. flexibility and the ability to adjust to changing situations and uncertainty in clinical situations. 8. affective skills and appropriate demeanor and rapport that relate to professional education and quality patient care. Candidates for selection to the Athletic Training Education Program will be required to verify they understand and meet these technical standards or that they believe that, with certain accommodations, they can meet the standards. The Student Disability Resource Center, (phone # , or uwf.edu/sdrc) will evaluate a student who states he/she could meet the program s technical standards with accommodation and confirm that the stated condition qualifies as a disability under applicable laws.

5 If a student states he/she can meet the technical standards with accommodation, then the University will determine whether it agrees that the student can meet the technical standards with reasonable accommodation; this includes a review a whether the accommodations requested are reasonable, taking into account whether accommodation would jeopardize clinician/patient safety, or the educational process of the student or the institution, including all coursework, clinical experiences and internships deemed essential to graduation. READ AND SIGN ONLY ONE STATEMENT BELOW: I certify that I have read and understand the technical standards for selection listed above, and I believe to the best of my knowledge that I meet each of these standards without accommodation. I understand that if I am unable to meet these standards I will not be admitted into the program. Signature of Applicant Date I certify that I have read and understand the technical standards of selection listed above and I believe to the best of my knowledge that I can meet each of these standards with certain accommodations. I will contact the SDRC Office (phone # , or uwf.edu/sdrc) to determine what accommodations may be available. I understand that if I am unable to meet these standards with or without accommodations, I will not be admitted into the program. Signature of Applicant Date

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