Onondaga Community College Athletics First Year Student-Athlete Pre-participation Health Questionnaire

Transcription

1 Onondaga Community College Athletics First Year Student-Athlete Pre-participation Health Questionnaire (Please fill this out in pen and take time to carefully read this and fill it out as accurately as possible. If you are not sure of a question, please ask your parent/guardian or the certified athletic trainer on staff for help.) Name: Academic Year: Sport: Birth Date: Age: Social Security # or Student ID #: Parent/Guardian Name(s): Permanent Address: City/State/Zip: Home Phone: Year: (circle one) FR SO Campus/Local Address (if different from permanent address): City/State/Zip: Local Phone: Athlete s Cell Phone: Emergency Contact Information (Name, relationship to you, and numbers they can be reached at): Address: Please circle Yes (Y) or No (N) for each question. If you answer Yes to a question, please provide a detailed explanation 1. Has a doctor ever denied or restricted your participation in sport for any reason? Y/N _ 2. Do you see a doctor on a regular basis for a medical condition (i.e. epilepsy, seizures)? Y/N _ 3. Do you wish to see a doctor for a current health problem or injury? Y/N _ 4. Have you ever been treated or informed by a physician that you have diabetes? Y/N 5. Do you have asthma? Y/N Please indicate medication(s) used. 6. Have you been diagnosed with a heart murmur? Y/N _ 7. Are you presently taking any medication(s)? Y/N

2 8. Do you have any allergies to medicine, foods, or insect bites/stings? Y/N If so, what are the signs or symptoms of an allergic reaction: 9. Have you ever had heat cramps, heat stroke, or do you have sensitivity to the cold? Y/N 10. Have you ever experienced any of the following during exercise: chest pain; difficulty breathing, coughing or keeping up; dizziness; passing out; an irregular heartbeat; or elevated blood pressure? Y/N _ 11. Have you ever experienced any fainting spells, headaches, blackouts, concussions, or been knocked out? Y/N 12. Do you have eye or vision troubles? Y/N If so, do you wear eye glasses or contact lenses? Y/N _ 13. Do any of your family members have a blood disorder (i.e. Sickle Cell Anemia)? Y/N _ 14. Has any family member been diagnosed with heart disease, or died suddenly, before the age of 50 due to heart disease or a heart problem? Y/N 15. Have you ever been hospitalized for any condition or major illness? Y/N 16. Have you ever had a non-orthopedic surgery (wisdom teeth, appendix, hernia, etc)? Y/N 17. Have you sustained any injuries (e.g. sprain, strain, fracture, dislocation, concussion) to the following areas? Head YES NO Neck YES NO Shoulder YES NO Elbow YES NO Wrist YES NO Hand/Finger YES NO Back YES NO Hip YES NO Thigh YES NO Knee YES NO Calf/Shin YES NO Ankle YES NO Foot YES NO If yes, please explain 18. Have you received orthopedic surgery for any of the above bone or joint injuries? Y/N 19. Have you fully recovered from and are you back to full participation for any injury listed? Y/N 20. FEMALES ONLY: How many periods have you had in the last 12 months? Additional Comments: I verify that all the above information is accurate and complete. I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct and that failure to disclose previous medical conditions may result in my removal from the team. I understand that the Onondaga Community College Athletics Department is not responsible for expenses related to pre-existing conditions. Signature of Athlete: Date:

3 Sports Physical Examination Form VITALS EXAMINATION Athletes Name: (To ONLY be filled out by person qualified to perform sports physical.) Height: Weight: Eyes: Are corrective glasses or contacts worn during participation: YES NO Left: 20/ Corrective Left: 20/ Right: 20/ Corrective Right: 20/ Blood pressure: Pulse: HEENT: LUNGS: HEART: ABDOMEN: SPINE: ORTHOPEDIC: HERNIA/GENT: PHYSICAN COMMENTS: MEDICAL STATUS: [CLEARED] [CLEARED WITH RESTRICTIONS] [FAILED] Examining Physician: Date: Office Stamp:

4 Onondaga Community College - Student-Athlete Medical Acknowledgement Name: Sport: Date of Birth: Assumption of Risk Injury is an inherent and assumed aspect of sport. I understand that through my participation in intercollegiate athletics at Onondaga Community College, I am subject to possible injury, and also understand that by my participation, I accept the responsibility of such risk, whether caused by conditions beyond anyone's control or even by the ordinary negligence of those involved. I understand that those who are responsible for the conduct of my sport have taken reasonable precautions to minimize such risks. I also understand that it is my obligation to prepare myself appropriately physically, mentally and emotionally to participate, and to fully understand and follow all established safety methods and rules of the game including the proper use of protective equipment and sport techniques. Information Release Authorization I authorize all Athletic Trainers and Physicians working with Onondaga Community College to provide to my parents or guardians as well as coaches, college personnel, and medical personnel, all information concerning my health care, injury, rehabilitation, treatment, and health status. This information is to be used for the purpose of athletic participation, continuing collegiate enrollment, or for accessing the insurance coverage under the policy which covers medical treatment and costs for me. The College is also authorized to obtain necessary and relevant medical information and records from past or present health care/medical providers. Again, this information is to be used for the purpose of advising responsible persons of the studentathlete s health or injury status for the purpose of athletic participation, continuing collegiate enrollment, or for accessing the insurance coverage under the policy which covers medical treatment and costs for me. Insurance Coverage I understand that to participate in intercollegiate athletics at Onondaga Community College (including tryouts or practice) I must provide proof of, and maintain throughout my participation either as an individual or on my parent or legal guardian s plan, accident insurance coverage that covers athletic participation. I understand that pre- existing conditions, non-athletic related injuries, injuries that occur during the summer or the off-season, or injuries that occur in informal intercollegiate activity without on-site supervision by a coaching staff member are my financial responsibility. I understand that any bills related to the assessment, treatment and rehabilitation of injuries occurring while I am representing the College in formal intercollegiate activity with on-site supervision by a coaching staff member, must be initially submitted to health insurance plans of me and my parents or guardians. Costs not covered under either my personal or my parent s or guardian s policy can then be submitted to College s Basic Athletic Accident Policy for review and consideration for payment and any costs not paid by the combination of the my primary insurance and the College s secondary policy, are the responsibility of the me and my parent(s) or guardian(s). Authorization, Agreement, and Consent I hereby authorize any emergency medical treatment that may become necessary while participating as a member of the Onondaga Community College athletic program. I agree to report any and all injuries occurring as a result of practice or competition to the Athletic Trainer within three days from the occurrence and I hereby further consent and give permission to Onondaga Community College to facilitate and provide medical treatment and/or care as deemed necessary by the College s medical staff for my health and well-being. By signing this, I also acknowledge that I have read, understand, and agree to all Onondaga Community College Student-Athlete Medical Requirements & Procedures. This statement will remain in effect until such time as it is revoked in writing by me and a photocopy of this authorization and acknowledgement shall be deemed effective and valid as the original. Student-Athlete Signature: Date: (To be signed by Parent/Guardian if the athlete is younger than 18 years of age on date of physical) Parent/Guardian Signature: Date:

5 Onondaga Community College - Student-Athlete Concussion Statement I,, acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff of Onondaga Community College (e.g., Athletic Trainer (ATC) and Team Physician). ( ) the following information below. I have read and understand the Concussion Fact Sheet for Student-Athletes. A concussion is a brain injury, which I am responsible for reporting to the Athletic Trainer (ATC) and coach. 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. If I suspect a teammate has a concussion, I am responsible for reporting the injury to the Athletic Trainer (ATC) and coach. 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. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve. I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. No helmet can prevent all head and neck injuries a player might receive while participating in sports. I have been provided with the Concussion Fact Sheet for Student-Athletes on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to my medical staff. After reading the Concussion fact sheet, I am aware of the following information. I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. By signing below, I acknowledge that Onondaga Community College Athletic Department has provided me with specific educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I, have read the above and agree that the statements are accurate. Student-athlete s name (print) Signature of student-athlete Date Parent/Guardian: (If under 18 years of age) Date

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7 Onondaga Community College - Student-Athlete Insurance Information The following information is necessary in order to determine and activate the benefits available to your child in the event of an athletic injury. A copy of the front and back of your insurance card(s) must be attached along with dental/vision insurance information if applicable. Student Athlete Information Name of Athlete Sport Date of Birth Address (Campus) Campus Phone Home Address Home Phone City State Zip Social Security # Cell Phone The following information must be fully completed, signed, and returned prior to your son or daughter begins athletic participation. FATHER/GUARDIAN/SPOUSE/SELF (circle one) Name: DOB Home Address: Employer s Name: Employer s Address: Home Telephone #: Work Telephone #: Name of Group Insurance Company: Telephone #: Policy/Group #: Is your dependent son/daughter covered under the above policy? YES NO MOTHER/GUARDIAN/SPOUSE/SELF (circle one) Name: DOB Home Address: Employer s Name: Employer s Address: Home Telephone #: Work Telephone #: Name of Group Insurance Company: Telephone #: Policy/Group #: Is your dependent son/daughter covered under the above policy? YES NO Please indicate which insurance is primary: Father/Guardian Mother/Guardian Self Is a primary care physician required: YES NO Please indicate the name and phone # of the PCP: Does the plan(s) include out of area coverage? YES NO I hereby certify the answers provided are true and complete to the best of my knowledge, and if there are any changes to this information that I will notify Onondaga Community College Sports Medicine Staff immediately. Father/Guardian Signature Date Mother/Guardian Signature Date Student Athlete Signature Date