Welcome Back: As a student-athlete, you will be required to participate in a comprehensive physical exam given by the athletic training staff.

Transcription

1 Welcome Back: As a student-athlete, it is necessary for us to gather pertinent medical information in order to determine if you are medically eligible to participate in intercollegiate athletics. Enclosed, you will find a packet of forms that require your attention. When completing these forms, please answer all questions to the best of your knowledge. Below is a list of forms followed by a brief description. If you have any questions, please feel free to contact one of the athletic training staff members via the numbers listed below. As a student-athlete, you will be required to participate in a comprehensive physical exam given by the athletic training staff. ü ü ü ü MEDICAL HISTORY: This will inform us of any previous medical problems and hopefully prevent any further problems from occurring. HEALTH INSURANCE INFORMATION FORM: A photocopy of both sides of all insurance cards (medical, dental, vision, prescription) must be attached to the completed form. STUDENT-ATHLETE PERSONAL INFORMATION FORM: This form provides contact information in the event of an emergency. BIOLOGICAL TESTING CONSENT FORM: By signing this form, you are indicating your understanding of the program and your agreement to be screened for banned substances. Screening takes place randomly throughout the year for all athletes. Participation in athletics is contingent upon adherence to the program and the signing of the consent form. ü INFORMATION RELEASE AUTHORIZATION FORMS: These forms gives the athletic training staff permission to release your medical history to team physicians, coaches, athletic staff members, student athletic trainers, parent(s)/ guardian(s), teammates, and professional scouts. These forms are required to be completed only once during your athletic career at USF. ü NCAA AND USF POLICY REGARDING LIABILITY: This form allows us to provide emergency medical care to you and terminate participation for health reasons at any time. ü CONCUSSION MANAGEMENT PROTOCOL: this document states that you have where provided and read the information provide on the NCAA and National Athletic Trainers Association recommendations on Concussion Management. If you have any questions please feel free to contact your team Athletic Trainer or any available Athletic Trainer in the Athletic Training room at (813)

2 Welcome back to the University of South Florida and participation in NCAA Athletics. It is our goal to provide you the student athletes with the best possible athletic health care. To achieve this goal, we will need your assistance with a variety of matters. If your insurance does NOT have current medical insurance that covers NCAA Athletics, it is highly advisable that you obtain some form of coverage. We currently work with an insurance agency that offers primary athletic insurance for student athletes. Please contact us if you have questions or would like more information. If you have a managed care insurance policy (HMO, POS) that requires the use of a Primary Care Physician (PCP), we strongly urge you to change your student s PCP to one of our USF team physicians. Most insurance companies will allow you to change the PCP of one family member without affecting the PCP for any other family members covered by the plan. Changing your son/daughter s PCP will benefit you and your family in many ways: 1. Allow your son/daughter easy access to his/her PCP, as our USF team physicians are located on campus, less than a mile from our athletic facilities 2. Expedite your son/daughter s medical care by removing the need for a prior approval from another PCP before seeing our team physicians 3. Cut down on medical costs to you in the event a non-athletic injury does occur; non-athletic injuries and illnesses are not covered by the USF policy and all costs will be the responsibility of the student athlete 4. Allow for better communication regarding injuries between all parties involved (including athletic trainers, team physicians, student athletes and parents) To change the primary care physician for your son/daughter, simply contact your insurance carrier at the phone number listed on your insurance card. The insurance company will ask you for the name of the physician of which you would like to switch; our head team physician s name and address is listed below for your convenience. Please notify the Sports Medicine Department at (813) once the change of PCP has been completed. Dr. Eric Coris Bruce B Downs Boulevard USF Medical Center Tampa, FL (813) The USF Athletic Department athletic accident policy provides insurance for a student athlete s injuries incurred while participating in a USF sanctioned practice or game. The USF athletic accident insurance policy is excess or secondary to any other collectible insurance benefits. Any claim for benefits must be first filed with the student athlete s primary insurance company. The USF policy will cover remaining medical expenses at the reasonable and customary level. This is where we will need your assistance. It is imperative that ALL bills, Explanation of Benefits Statements or other claim correspondence is forwarded to Janet Britton-Rodgers and the athletic training team. In order for USF to expedite the payment process, we need all information that is sent to your son/daughter or you directly. This will allow us to process the athletic claims in a timely fashion and make sure all primary insurance is being utilized. This will also ensure your account is not sent to collections for lack of payment. If you have any questions regarding athletic insurance or these procedures, please feel free to contact us at your convenience. We very much appreciate your attention to this matter and look forward to having your son/daughter participate in the University of South Florida Athletics. Go Bulls! Janet Britton-Rodgers Insurance Supervisor University of South Florida Athletics

3 MEDICAL HISTORY Name Date Date of Birth / / Sport Family History Does anyone in your family have a history of medical problems? If yes, explain: Mother: Living: Age of Death: Cause of Death: Father: Living: Age of Death: Cause of Death: Brother(s): Living: Age of Death: Cause of Death: Sister(s): Living: Age of Death: Cause of Death: Has anyone in your family ever been diagnosed with: Sudden unexplained death Relationship: Alcohol/Substance Abuse Relationship: Asthma Relationship: Cancer Relationship: Diabetes Relationship: Heart Disease (of any kind) Relationship: High Blood Pressure Relationship: Marfan Syndrome Relationship: Migraines/Severe Headaches Relationship: Osteoporosis/Bone Disorder Relationship: Seizures/Epilepsy Relationship: Sickle Cell Disease/Trait Relationship:

4 Current Medical Conditions: Are you currently under medical supervision for an injury/illness? If yes, explain: Do you have a current ongoing or chronic illness? If yes, explain: Surgery/Hospitalization: Have you ever had surgery? Date: Date: Date: Surgery: Surgery: Surgery: Have you ever been hospitalized for a reason other than surgery? Date: Reason: Date: Reason: Have you ever been advised to have a surgery not yet performed? If yes, explain: Medications: Do you regularly use any prescription medication? If yes, explain: Do you regularly use non-prescription medication? If yes, explain: Do you regularly take any dietary supplements? If yes, explain: Have you ever taken supplements or vitamins to help you gain/lose weight in order to improve your performance? If yes, explain: Alleriges: Are you allergic to any of the following: Aspirin Food (specify) Dust/pollen Insect stings (specify) Penicillin Sulfa Drugs Novocaine Other Drugs (specify)

5 Illnesses: Have you had any of the following illnesses: Chicken Pox Date: Diabetes Date: Hepatitis Date: Measles Date: Mononucleosis Mono Date: Pneumonia Date: Have you ever had any of the following: Anemia Sickle Cell Disease/ Sickle Cell Trait Eye injury or other eye problem Hearing loss Severe tooth or gum trouble Severe skin problems (rash, acne, burns, etc.) Do you have loss or seriously impaired function of any paired organ? Ear Eye Kidney Ovary Testicle Lung Cardiovascular System: Do you get more fatigued (tired) during exercise, or get fatigued earlier during exercise than your teammates? Do you become more short of breath during exercise than your teammates? Have you ever fainted or passed out during or after exercise? Have you ever had chest pains during or after exercise? Have you ever been told that you have high blood pressure (hypertension)? Have you ever been told that you have a heart murmur? Have you ever been told that you had high cholesterol (hyperlipidemia)? Has a physician ever ordered heart testing (for example: EKG, Echo, stress test, holter monitor)? If yes, please explain: Have you ever been diagnosed with any type of heart disease (hypertrophic cardiomyopathy, coronary artery abnormality, heart infection, heart valve disease, Marfan s Syndrome, etc)? If yes, please specify: Have you ever been told that you need to take medication before seeing a dentist? Have you ever had a racing heart or skipped heart beats? Has anyone in your family died of heart problems or sudden death before the age of 50? If you answered yes to any of the above questions, please explain:

6 Respiratory System: Do you cough, wheeze, have difficulty breathing, or get short of breath during exercise? If yes, how often? Have you ever been diagnosed with asthma? If so, is your asthma well controlled? Please check one: I have symptoms from my asthma: daily More than twice per week Less than twice per week Hardly ever Do you use an inhaler? If yes, what kind? Do you have seasonal allergies that require medical treatment or medication? Neurological System: Have you ever had a head injury or a concussion? Date: Explain: If so, how many concussions? Have you ever been knocked out, unconscious, or lost your memory? Date: Explain: Have you ever had a seizure? Date: Explain: Have you ever had a stinger, burner, or pinched nerve? Date: Explain: Heat Illnesses: Have you ever had heat stroke or heat exhaustion? If so, please explain: Have you ever had muscle cramps caused be the heat? How often? Have you ever been dizzy or fainted in the heat? How often? Have you ever been confused in the heat? How often? Have you ever been hospitalized for a heat related condition? Nutrition: Do you want to weigh more or less than you currently do? Do you frequently lose weight or gain weight to meet the requirements of your sport? Would you be interested in seeing a sports nutritionist? Have you ever been told you were Anemic by a physician?

7 Women Only: What was the date of your last menstrual period? When was your first menstrual period? How many periods have you had in the last year? What was the longest time between periods in the last year? My periods are now (circle one): Regular every days Irregular every 36 days or more Absent no periods for the past three months Are you currently taking a form of birth control? If yes, what kind? Is there a history of osteoporosis in your family? Is there a history of repeated fracture in anyone in your family? Have you had repeated fractures or repeated stress fractures before? Protective Devices: Do you wear contacts? Do you wear glasses? Do you wear orthotics in your shoes? Do you wear any corrective braces or supports? If yes, what? Musculoskeletal System: Have you ever injured any of the following extremities that caused you to miss a week or more participation in your sport? Hip Left / Right Date: Explain: Groin Left / Right Date: Explain: Thigh Left / Right Date: Explain: Knee Left / Right Date: Explain: Shin/Calf Left / Right Date: Explain: Ankle Left / Right Date: Explain: Foot/Toes Left / Right Date: Explain: Skull/Face Left / Right Date: Explain: Teeth/Jaw Left / Right Date: Explain: Neck Left / Right Date: Explain: Back Left / Right Date: Explain: Shoulder Left / Right Date: Explain: Upper Arm Left / Right Date: Explain: Elbow Left / Right Date: Explain: Forearm Left / Right Date: Explain: Wrist Left / Right Date: Explain: Hand/Fingers Left / Right Date: Explain:

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10 Other Medical Conditions: Have you ever been told, for any reason, that you should not participate in sports? If yes, explain: Do you know of, or believe, there is any reason that should prevent you from participating in intercollegiate athletics? If yes, explain: I certify that the answers to the preceding questions are correct and true to the best of my knowledge. I understand that passing the physical exam does not necessarily mean that I am physically qualified to engage in intercollegiate athletics, but only that the examiner did not find medical reason to disqualify me from participation. Signature of Student-Athlete Signature of Parent/Guardian if under 18 years of age Date Date MEDICAL CONSENT Permission is hereby granted to the attending physician, USF Sports Medicine Staff, or other medical personnel to proceed with medical treatment, minor surgical treatment, and x-ray examination. In the event of serious injury or illness, I understand that an attempt will be made by the appropriate medical personnel to contact my parents or legal guardian. If medical personnel are not able to communicate with the responsible party, the treatment necessary for my health will be provided. Signature of Student-Athlete Date Signature of Parent/Guardian if under 18 years of age Date

11 Student-Athlete Health Insurance Information Form Dear Parent/Guardian: We have an established athletic insurance policy providing medical coverage for your son/daughter for injuries that occur while participating in Intercollegiate Athletics. This medical coverage is secondary to medical/dental/vision insurance provided by the parent/guardian. After primary benefits are considered, USF will process the remaining balance for payment. Please complete this form entirely. Please attach copies of all insurance cards, front and back. StudentAthlete Sport DOB USF I.D. Local Phone Number ( ) Cell Phone Number ( ) If Uninsured initial here: Insurance Subscriber Name SS# DOB Address Employer Work.Phone Athlete s Relationship to Subscriber Primary Medical Insurance Insurance.Company Customer.Service# Claims.Address Member# Policy# Group# PPO or HMO Primary Care Physician Phone# Secondary Insurance (circle one) Prescription, Dental, Vision Insurance.Company Customer.Service# Claims.Address Member# Policy# Group# PPO or HMO Primary Care Physician Phone# Secondary Insurance (circle one) Prescription, Dental, Vision Insurance.Company Customer.Service# Claims.Address Member# Policy# Group# PPO or HMO Primary Care Physician Phone# IN CASE OF EMERGENCY CALL Name: Relationship: Address: Home Phone #: ( ) Cell Phone #: ( ) Work Phone #: ( ) I acknowledge receiving the University of South Florida s intercollegiate athletic medical policy. I understand the university s responsibility to a student athlete who becomes injured or ill as a result from participation in intercollegiate athletics. Student Athlete s Signature: (date)

12 BIOLOGICAL SPECIMEN TESTING CONSENT FORM 1. I hereby consent to be tested to determine if I have utilized any substance on the University of South Florida list of banned drug classes as set forth in the University of South Florida s Substance and Abuse Policy, by providing a biological specimen as requested by the director of intercollegiate athletics or designee. 2. I agree to provide such biological specimens at the time and location and under conditions for collection, as determined by the director of intercollegiate athletics or designee, at various times throughout the year, with or without prior notice. 3. I hereby authorize the director of intercollegiate athletics or designee to send my samples to the laboratory of the university s choice for actual testing and authorize the director of intercollegiate athletics or designee to receive test results. 4. I hereby authorize the director of intercollegiate athletics or designee to release all information and records, including test results, that may be made or received relating to the screening and testing of my biological specimens to the university s respective head coach and associate athletic director for sports and program services, or their designees, for their use in supervision and administration of the university s athletic program. I acknowledge that while certain medical information may be released to the media by virtue of my participation in USF Intercollegiate Athletics, the results of drug tests will not be released or reported. I further acknowledge and agree that my parent/ guardian will be notified of the results of any positive test result(s). 5. I acknowledge that I have read a copy of the University of South Florida Drug Abuse Policy and Procedures, including the University of South Florida Banned Drug Class List, and that I have had an opportunity to ask questions regarding them. I understand the provisions therein and I agree to abide by those provisions including those specifically related to possible penalties for positive test results. 6. I hereby release and discharge the University of South Florida and the Board of Trustees of the State University System of South Florida, their officers, employees and agents from all claims and causes of action created by or arising out of any act or omission related to the implementation of the University of South Florida Drug Abuse Policy and procedures. 7. I have read this Consent Form, understand the terms in it, their legal significance and sign voluntarily. 8. I understand that I may revoke my consent to participate at any time in the University of South Florida Drug Abuse Policy. In doing so, I understand and agree that I will immediately be banned from participation in intercollegiate athletics at University of South Florida and will immediately forfeit any related athletic scholarships or financial aid. Student Athlete Name (Print) USF ID Number Student-Athlete Signature Date Birth Date Parent / Guardian (if under 18 years of age) Date Sport

13 INFORMATION RELEASE AUTHORIZATION I,, Give consent for my medical records to be released to any USF Team physician involved in the care of my illness or injury; or to a physician appointed by the USF Athletic Training Staff. Athlete s Signature: Date: / / I also give consent for the USF Athletic Training Staff to release medical information to the sports information department, media, or a scout/ representative of any professional or amateur athletic organization seeking such information. I acknowledge that this type of information may be reported in the media as a result of my participation in USF Intercollegiate Athletics, except that no results of drug tests will be released or reported. ( Body part affected by injury or illness ( Nature of the injury (sprain, fracture, etc.) ( Status of the athlete for same day and future competition Athlete s Signature: Date: / / ***This release remains valid until revoked in writing and delivered to the Assistant Director of Athletics for Sports Medicine. For purposes of this authorization, medical information can include but not be limited to, information concerning illness, injury, treatment, rehabilitation, physicians names or referrals, and/or prognosis.

14 SUPPLEMENT/MEDICATION WAIVER I will not consume any nutritional supplement* other than those provided or having written approval from Athletic Department Sport Performance staff, Assistant AD/Head Strength & Conditioning Coach or Assistant AD/Director of Sports Medicine). I will notify Sports Medicine staff and Team Physicians of any current prescription medications I am presently taking prior to receiving any OTC* and Prescription medications* from Sports Medicine staff. *Nutritional supplement is any product (powder, pill, liquid, beverage, tablet, etc.) designed to supplement the diet which includes one or more of the following ingredients: vitamins, minerals, herbs, botanicals, amino acids, calorie boosters, constituents, extracts, or any combination of these ingredients. *OTC medications are medications that can be purchased over the counter from retailers such as drug stores, pharmacies, grocery stores and convenience stores. A prescription is not needed for these medications. Typical OTC medications include Tylenol, aspirin, ibuprofen, cough and cold formulas, and medications for allergies, constipation, diarrhea and nausea. *Prescription medications are generally more potent than those sold over-the-counter (OTC) and may have more serious side effects if inappropriately used. Therefore, these medications are only sold under a doctor s direction. All supplements must be approved by the three individuals listed above. Please list supplements/medication you are currently taking or have taken in the past 3 months: Print Name: Signature: Date:

15 LIABILITY WAIVER I,, understand that there are risks in participating in the sport of. I am voluntarily assuming the responsibility for any such risks. Therefore, I consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the University of South Florida and agree that the Sports Medicine staff may terminate my participation at any time and for any reason. I waive and release the University of South Florida, the Board of Trustees (or any other entity designated by Florida law to manage, operate, and/or oversee the University of South Florida) and the officers, agents, employees, and any students acting on behalf of either the University of South Florida or the Board of Trustees, and the heirs, assigns or successors in interest of any and each of them from any and all Liability which may result or arise from either my athletics participation or any medical treatment I may receive. If any portion on this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any Court of competent jurisdiction, the remaining portions of this release shall not be affected. Signature of Participant USF ID Number Date Date of Birth Signature of Parent/Guardian if Participant is under 18 years of age Date

16 ADHD BANNED SUBSTANCE MANAGEMENT AND DOCUMENTATION 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 has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. With respect to the use of banned medications used to treat Attention Deficit Hyperactivity Disorder (ADHA), Attention Deficit Disorder (ADD) and/or other medical conditions (Ritalin, Stattera, Adderall, Concerta etc.). The NCAA requires documentation of a comprehensive clinical evaluation to support treatment with NCAA banned medications and a current prescription. At a minimum, student athletes prescribed NCAA banned medications for the treatment of ADHD, ADD, and/or like conditions must provide the following documentation from the prescribing physician: 1. Evidence of comprehensive clinical evaluation (recording observations and results from standardized rating scales and/or neuropsychological testing) a physical exam and any lab work (attaching all documentation); A simple statement from a prescribing physician that he/she is treating the studentathlete for ADHD, ADD, and/or like conditions with the prescribed medication IS NOT adequate documentation. 2. Statement of diagnosis, including when diagnosis was confirmed 3. History of ADHA, ADD, and/or like conditions treatment (previous and ongoing) 4. Recommended treatment (attached current prescription) 5. Statement that a non-banned ADHD alternative has been considered and why banned stimulant was prescribed 6. Annual follow-up with prescribing physician and update letter or copy of medical record is required in each year of eligibility. The above documentation must be on file with the University of South Florida Sports Medicine Department in order for the student-athlete to participate in intercollegiate athletics at the University of South Florida. if you have specific questions regarding the NCAA Bylaws related to banned substances, drug testing, and/or medical exceptions can view the NCAA website (

17 ADHD BANNED SUBSTANCE I, affirm that I have been informed by the University of South Florida Sports Medicine Department about the NCAA Banned Substance List and NCAA Medical Exceptions Policy as it specifically pertains to the use of banned stimulant medications (Ritalin, Stattera, Adderall, Concerta, ect.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and/or like conditions. I attest that (initial (a) or (b) below): (a) I AM NOT presently taking and/or have taken within the last 12 months any banned medications (e.g. Ritalin, Stattera, Adderall, Concerta, ect.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD) and/or other medical conditions. I understand that I am to immediately notify a member of the USF Sports Medicine Staff should I ever be prescribed the aforementioned medications and that I must obtain and submit appropriate documentation to the USF Sports Medicine Department from the prescribing physician. (b) I AM presently taking and/or have taken within the last 12 months banned medications (e.g. Ritalin, Stattera, Adderall, Concerta, ect.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD) and/or other medical conditions. I understand that I must obtain and submit appropriate documentation to the USF Sports medicine Department from my prescribing physician. I have truthfully represented whether or not I am currently taking an NCAA Banned medication. If I am currently taking a NCAA banned medication or am prescribed one at a future date, I understand and agree that I will notify a member of USF Sports Medicine Staff and provide appropriate documentation in order for me to participate in intercollegiate athletics at the University of South Florida. Student-Athlete Signature Parent/Guardian if under the age of 18 years Date Date

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