AUSTIN PEAY STATE UNIVERSITY - RETURNING STUDENT ATHLETE MEDICAL UPDATE FORM

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1 AUSTIN PEAY STATE UNIVERSITY - RETURNING STUDENT ATHLETE MEDICAL UPDATE FORM Name: Last First Middle Birthdate: SS#: Sport: Emergency Contact: Phone #: Height: Weight: Blood Pressure: Heart Rate: 1. Have you EVER Yes No Comments Been diagnosed with diabetes? Been told you have asthma? If yes, how many times in the last month have you used your emergency inhaler? XX XX Seen a cardiologist or had any cardiac (heart) testing performed? Felt dizzy, light-headed or passed out during or after exercise? Had chest pain or a rapid heartbeat during or after exercise? Been diagnosed with a concussion in the last 18 months? 2. Since last season (or May of this current year) have you Had any new food allergies? Had any new allergies to medications? Had any other new allergies? Been hospitalized? Had any major illnesses? Been under the care of a Physician? Had any major injuries? Had diagnostic testing performed (X-rays, MRI, etc)? Had any surgical procedures performed? Seen an eye doctor or fitted for glasses or contacts? Been to the dentist or had dental work performed? Been diagnosed with ADD/ADHD Yes No Comments 3. Medications / Supplements - Please list ALL over-the-counter and prescription medication and /or supplement that you are CURRENTLY TAKING or HAVE TAKEN in the PAST 18 MONTHS and FOR WHAT PURPOSE INCLUDE ADD/ADHD MEDICATION: Medication and / or Supplement Dosage Purpose Dates Page 1 of 2

2 4. FEMALES ONLY (Males skip to section 5 & continue) How many days do your menstrual periods last? How often do you have a menstrual period? How many menstrual periods did you have in the last year? What was the longest time between periods in the last year? When was your last menstrual period? Have you ever been pregnant? An abortion? Have you been treated for any gynecological or female health issue in the last 12 months? Comments 5. Do you currently have any of the following symptoms or problems? Frequent headaches Visual changes Ringing in ears Sore throats Sinus congestion Difficulty breathing Recurring coughing Chest pain Yes No Yes No Abdominal pain Muscle cramps Frequent nausea Frequent vomiting Frequent diarrhea Rectal bleeding Unusual fatigue Trouble sleeping Have you ever experienced any problems or injuries due to heat? Are you currently sick / ill? Do you have any injuries that have not completely healed since last season? Are you currently injured in any way? Do you have any medical or health problem that you are currently receiving medical treatment for? Is there any reason that you are not able to participate in athletics? Do you have any current problems / concerns you would like to see a Physician for at this time? The undersigned, herewith, Yes No Comments A. Understands that he/she must refrain from practice or play during medical treatment until he/she is discharged from treatment or given written permit by the attending physician to resume participation: B. Certifies that the answers to these questions are correct and true: C. Fully realizes that the Austin Peay Athletic Department cannot be held responsible for any previous medical condition(s) that he/she might have. Student-Athlete Date of Birth Student-Athlete ID Number Sport Student Athlete s Signature Date Parent or Legal Guardian s Signature if Student Athlete is under 18 Date Page 2 of 2

3 AUSTIN PEAY STATE UNIVERSITY ATHLETICS INSURANCE INFORMATION We are happy to have your son or daughter participating in Athletics at Austin Peay State University. We want to provide the best medical care possible for all our athletes and because of this we have taken out an insurance policy to help cover any possible injury that they might suffer while participating in sports here. Our athletic insurance policy which provides insurance for your son or daughter for injuries occurring while participating in the play or practice of intercollegiate sports is "EXCESS" or "SECONDARY" to any other collectible group insurance benefits. This simply means that any claim for benefits must first be filed with the group insurance company providing coverage to your son or daughter through your employer or your spouse's employer. After they have paid all available benefits, our athletic insurance company will pay any remaining amounts. We, as the school, do not have the option of waiving the requirement of filing with your group insurance. The NCAA has also purchased a Lifetime Catastrophic Athletic Insurance Policy for our athletes. This policy covers student-athletes who are catastrophically injured while participating in a covered intercollegiate athletic activity. It has a $75,000 deductible, which would be met by your insurance coverage and our secondary policy, and is supplemental coverage in the event of a catastrophic injury. We certainly hope that nothing serious happens to your son or daughter, but should a serious injury occur, we have a policy that will help defray costs associated with the injury. More information on this program can be found on the NCAA s web-site at Also, to help prevent confusion concerning our coverage, it is important that you know that our insurance will not cover any injury/illness that does not happen as a direct result of organized weight training and conditioning activities and practices or games (e.g., illness, accidents at the dorm, etc., are not covered). The Athletic Department will not be responsible for any medical bill incurred by a student athlete who sees a physician, has x-rays, or receives treatment without the prior knowledge of a full-time staff athletic trainer. PLEASE NOTE: 1. Most employer's group insurance allow dependent coverage to be continued to age 25 if the dependent is a full-time student. DO NOT drop dependent coverage while your son or daughter is participating in intercollegiate athletics. 2. Claims against your group insurance plan DO NOT increase your individual insurance premiums. 3. By utilizing both your group insurance and our athletic insurance, all bills will be paid in full for athletic injuries. You will not be required to pay your group insurance deductible or any coinsurance amounts. 4. Austin Peay State University and its insurance carrier can only pay for expenses that are allowable under the governance and guidelines of the National Collegiate Athletic Association. 5. If you have an HMO or PPO type of policy where a primary care physician has to refer any condition(s) to a specialist, please call you primary care physician to let them know your son/daughter will be going to college at Austin Peay State University. You may even wish to change their primary care physician to an Austin Peay team physician. 6. We will not file claims or pay for care given or referrals made by individuals other than Austin Peay State University team physicians or other Austin Peay State University medical personnel. 7. Any bills sent directly to you should first be filed with your own group insurance plan. Do make sure the Athletic Department's claim representative also receives a copy of these bills. The Athletic Department does not receive copies of the bills. 8. We cannot pay any bill for your son/daughter, no matter how small or for whatever reason, until this form is returned to Austin Peay State University. To help in the event that your son or daughter is injured while participating in athletics, please carefully read the following information and complete the enclosed form and return it to Austin Peay State University. Also, please enclose a copy of the front and back of your insurance card(s). If you do not have any insurance to cover your son or daughter, please write NONE on the form. Please return insurance forms to Joni Johnson, Head Athletic Trainer, c/o Austin Peay Athletics, Post Office Box 4515, Clarksville, TN Office phone ( 931) Fax (931) Also, If you have any questions, please feel to contact me at any time. Thank you very much for your cooperation concerning these matters. **PLEASE KEEP THIS PAGE FOR FUTURE REFERENCE **

4 Student-Athlete s Name Austin Peay State University Health Insurance Information / Authorization ** PLEASE RETURN TO ATHLETIC TRAINING ROOM DURING PRE-PARTICIPATION PHYSICAL** Sex Male Female Date of Birth Sport Permanent Address Phone # Social Security No. Street City State Zip FATHER S / GUARDIAN S INFORMATION MOTHER S / GUARDIAN S INFORMATION Name SS No. DOB Home Address Name SS No. DOB Home Address Home Phone Employer Employer Address Work Phone Insurance Company Address Policy / ID # Group # Insurance Company Phone # Type of Insurance- HMO PPO Indemnity Other Primary Care Physician Physician Phone # Is preauthorization necessary for medical/diagnostic services? Yes No Phone # Is your son / daughter covered under this policy? Yes No Home Phone Employer Employer Address Work Phone Insurance Company Address Policy / ID # Group # Insurance Company Phone # Type of Insurance- HMO PPO Indemnity Other Primary Care Physician Physician Phone # Is preauthorization necessary for medical/diagnostic services? Yes No Phone # Is your son / daughter covered under this policy? Yes No Please check one: I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained by my son/daughter. My son/daughter is NOT covered under my group insurance. PLEASE READ CAREFULLY! Austin Peay State University Department of Intercollegiate Athletics accident policy provides insurance for student-athletes with injuries occurring only when participating in the play or practice of intercollegiate athletics. This accident policy is considered EXCESS or SECONDARY to any other collectible group insurance benefits. Therefore, any claims for benefits must first be filed with the group insurance company providing coverage. Only after all available benefits have been exhausted will Austin Peay State University s Department of Intercollegiate Athletics insurance carrier consider payment for any remaining balances. I hereby authorize Austin Peay State University Department of Intercollegiate Athletics, hospitals, & physicians connected with or provided, to furnish information to insurance carriers concerning any illness, injury, & treatments & I hereby assign to the party all payments for medical services rendered to the student-athlete. I agree to supply any & all information requested by my primary insurance, Austin Peay State University Department of Intercollegiate Athletics & their excess insurance company in a timely manner. I hereby authorize Austin Peay State University Department of Intercollegiate Athletics and their excess insurance company to secure & inspect copies of case history records, lab reports, diagnoses, x-rays, & any other data pertaining to the injury/illness I am receiving care for or previous confinements of disabilities relevant to the care of the injury/illness. I hereby authorize Austin Peay State University Sports Medicine Department and/or my coach to hospitalize & secure treatment for me for any athletic injury/illness. A photocopy of this authorization shall be deemed as effective & valid as the original. I agree to notify Austin Peay State University Sports Medicine Department immediately upon any change in the above health insurance information. If I fail to do so, I fully understand that I may be responsible for any & all charges incurred. We, Austin Peay State University, do not have the option of waiving the requirement of filing with your group insurance. I hereby certify that I have read & understand the above statements, that any & all questions have been answered to my satisfaction, & that the answers provided are true, complete, & correct to the best of my knowledge. It is illegal to knowingly provide false information on this form. In the absence of the policy holder s signature, the signature of the covered student-athlete will be acceptable. Policy Holder s/ Student-Athlete s Signature Date

5 ** PLEASE RETURN TO ATHLETIC TRAINING ROOM DURING PRE- PARTCIIPATION PHYSICAL** Copy front of insurance card below Copy back of insurance card below

6 INSTRUCTIONS FOR RETURN OF PHYSICAL PAPERWORK: Save the completed document to a disc or USB drive. the completed document by attaching the file to the to johnsonj@apsu.edu. You will be asked to sign all forms upon your arrival for your preparticipation physical. If you are unable to these forms back in an attachment, after printing off & signing the completed forms, you can mail them to the following address: Joni Johnson, Head Athletic Trainer Austin Peay Athletics P.O. Box 4515 Clarksville, TN PLEASE BE SURE TO SEND THE FRONT AND BACK COPY OF ALL INSURANCE CARDS Page 14 of 14