SPORTS MEDICINE MEDICAL HISTORY

Transcription

1 SPORTS MEDICINE MEDICAL HISTORY Complete all forms in this packet and return to: Mary McLendon, ATC or fax: or mail: P.O. Box 5327, Mississippi State, MS Read the directions before each section CAREFULLY. Any incomplete packets and/or packets missing signatures will be returned. Student-athletes will not be allowed to participate until all forms are fully completed. If you have any questions, please contact: Mary McLendon, ATC

2 MISSISSIPPI STATE UNIVERSITY DEPARTMENT OF ATHLETICS- SPORTS MEDICINE MSU Sports Medicine March 2015 PRE-PARTICIPATION PHYSICAL EXAMINATION PROCEDURES AND GENERAL MEDICAL INFORMATION The Mississippi State University Athletic Department seeks to provide comprehensive athletic training services for its student-athletes, including preventive services, first aid, and physical rehabilitation. While your child is at Mississippi State, their health will be our main concern. Visit our website to learn more about our program; you ll find information about our staff, the pre-participation physicals process, and our facilities. The website can be accessed by clicking on the Sports Medicine link under Departments at Please do not hesitate to contact your child s athletic trainer if you have any questions throughout the year regarding their health; however, we encourage the student-athlete to be the first line of communication. We can provide the best care for the student-athlete when there is open and honest communication between them and their athletic trainer. Our contact information (sport assignment, phone number, address, etc.) can be found by visiting our website. Medical Certification for Individual Student-Athlete Participation: The Mississippi State University Athletic Department requires all student-athletes to complete a preparticipation physical examination prior to the student-athlete being issued equipment, being permitted to attend any practice or strength and conditioning session, and/or competing in any intercollegiate athletic activities. The pre-participation physical examination MUST be administered by a Mississippi State University Team Physician. The examination includes, but is not limited to: 1. Completion of the John C. Longest Student Health Center Health History Questionnaire (enclosed); Checklist: Completed both sides form Student-athlete signed the consent to treat (a parent should not sign unless the student-athlete is a minor) 2. Completion of the Mississippi State University Student-Athlete Health History (enclosed); Checklist: Completed both sides form Leave local address blank if you do not have an MSU/Starkville address yet Completed TDAP section If the student-athlete has had a TDAP (tetanus with pertussis) shot within the last five years, please have the medical facility or doctor who gave the shot fill in when the shot was administered and sign and stamp the form. If the TDAP shot is included on an official shot record, that will be acceptable. If we do not have proof of a TDAP shot within the past five years, the student-athlete will be required to receive a TDAP shot at physicals here on campus. We do not want to give repeat shots, so completing this information is very important. Provided information for eye doctor (if applicable) Answered all questions and gave explanations for any Yes responses Student-athlete signed the bottom of form

3 MSU Sports Medicine March Completion of the Mississippi State University New Female Student-Athlete Health History (enclosed, complete if applicable); Checklist: Answered all questions and gave explanations for any Yes responses Student-athlete signed form 4. Completion of the HIPAA Notice of Provider Privacy Practices (enclosed); This includes information about the HIPAA privacy practices for the Longest Student Health Center. You don t need to worry about the receipt mentioned at the top of the first page; the receipt is included at the bottom of the first form you completed. 5. Completion of the Consent to Treat Minor Patient Form (enclosed, complete if applicable); This form needs to be completed only if the student-athlete will not be 18 at their time of the on campus physical examination. 6. Completion of the NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment with Banned Stimulant Medication) (enclosed, complete if applicable); This form needs to be completed only if the student-athlete is using any medicine for the treatment of ADD/ADHD (see ADHD Medications below for additional information). 7. Completion of the MMR Immunization/ Shot Record (separate mailing); This form is sent to all students and will come directly from the university. Although we do not include it in this packet, it is very important to complete this form and return it to the school. If you need another copy of this form, you can print it at: 8. Completion of the Mississippi State University Department of Athletics Health Insurance Information/Authorization Form (separate mailing); 9. Completion of an Athletic Medical Examination and Orthopaedic Screening Examination by a Mississippi State University Team Physician and/or his/her designee; 10. Completion of a blood test as mandated by the NCAA for sickle cell trait/sickle cell anemia. The results of this test can take as long as hours, and student-athletes cannot begin participation until the results are received. Selected individuals may be required to complete additional tests and/or examinations as needed. Upon successful completion of the aforementioned pre-participation physical examination process, the student-athlete will receive approval/certification from MSU Sports Medicine and the Compliance Office to be issued equipment, and to participate in practice, strength and conditioning sessions, and/or competition. If, for any reason, the student-athlete is not approved/ certified for intercollegiate athletics participation, he/she will be notified by the Mississippi State University Team Physician and/or a member of the Mississippi State University Sports Medicine Department at the end of the preparticipation physical examination. Scholarship Student-Athletes: - Costs associated with any additional tests, consultations, and/or medical procedures needed to gain approval/certification for participation will be sent to the student-athlete s primary health insurance for payment first. - Costs not paid by the student-athlete s primary health insurance will be paid through the Mississippi State University Athletic Department.

4 MSU Sports Medicine March 2015 Non-scholarship/Walk-on/Tryout Student-Athletes: - All costs associated with any additional tests, consultations, and/or medical procedures needed to gain approval/certification for participation in intercollegiate athletics at Mississippi State University will be the responsibility of the student-athlete and/or his/her primary health insurance. No member of the Mississippi State University Athletic Department will permit a student-athlete to participate, nor will Mississippi State University provide insurance coverage to any student-athlete who has not completed the pre-participation physical examination procedure. Scheduling a Physical Examination (Scholarship Student-Athletes): Coaches will contact scholarship student-athletes and/or their families regarding specific dates and times for physicals. ADHD Medications: 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 (CSMAS) has a procedure to review and approve the use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The NCAA has a strict application of the NCAA Medical Exception policy, specifically for the use of banned stimulant medications (e.g. Ritalin, Strattera, Adderall, Concerta, etc.) that are used to treat Attention Deficit Hyperactivity Disorder (ADHD). Student-athletes who have been diagnosed with ADHD and/or have been prescribed stimulant medications should immediately notify a member of the MSU Sports Medicine Staff to begin the process of obtaining the necessary documentation. Student-athletes who have been treated since childhood with ADHD stimulant medications but do not have the pertinent records with regards to the diagnosis, management, and continuing evaluation must undergo a comprehensive evaluation to obtain the necessary documentation. At a minimum, student-athletes must provide the following documentation from the prescribing physician: 1. Description of the evaluation process which identifies the assessment tools and procedures; 2. Statement of the diagnosis, including when it was confirmed; 3. History of ADHD treatment (previous/ongoing); 4. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed; 5. Statement regarding follow-up and monitoring visits; and 6. Copy of the most recent prescription (as documented by the prescribing physician). This documentation should be on file with the MSU Sports Medicine Staff. The student-athlete should come to campus with the documentation or all documentation may be sent to: Mary McLendon, ATC Director of Sports Medicine P.O. Box 5327 Mississippi State, MS Secure Fax- (662) mkm13@msstate.edu

5 Drug Testing and Banned Drugs: MSU Sports Medicine March 2015 The Mississippi State University Department of Intercollegiate Athletics recognizes that drug and alcohol use and abuse is a significant problem in modern society. The abuse of chemical substances poses a serious threat to the physical and psychological well being of student-athletes. The National Collegiate Athletic Association (NCAA) has also recognized this issue and requires that all athletes under its jurisdiction be placed under its drug testing policies and program. The NCAA has established a year round drug testing program that includes on-campus testing as well as testing at all NCAA Championship events. To ensure both the wellbeing of our student-athletes and compliance with NCAA drug use regulations, Mississippi State University has established a year-round, comprehensive drug education and screening program. This program is designed to provide student-athletes with a means of obtaining support, assistance, and direction in dealing with drug and alcohol abuse. The NCAA will also conduct a year-round drug-screening program on campus, at the site of postseason events, and at any other time as determined by the NCAA. Enclosed you will find the most recent NCAA Banned Drugs Handout which will give you more information. The MSU drug testing policy can be reviewed on the MSU Athletics website ( by selecting Athletics then Compliance. You are also welcome to review the policy at my office, and the policy will be included in the Student-Athlete Handbook. I encourage you to review this information. A positive MSU or NCAA drug test for street drugs (including marijuana) or performance enhancing drugs can result in suspension from participation and ultimately a loss of scholarship. Nutritional/Dietary Supplements: The use of supplements has become widespread among athletes, and student-athletes have tested positive and lost their eligibility from using these products. Any supplement product or medication, even those that do not seem to be targeted to athletic performance, needs to be reviewed with the MSU Sports Medicine Staff. The NCAA mandates that each athletic department designate provide a staff member as a resource for questions about dietary supplements and NCAA banned drugs. All inquiries should be directed to the Director of Sports Medicine, Mary McLendon. Before consuming any nutritional/dietary supplement product, review the product and its label with the Director of Sports Medicine. Dietary supplements are not well regulated and may cause a positive drug test result. Even if a product is not known to contain a banned substance, any product containing a dietary supplement ingredient is taken at your own risk. Injury/Illness Reporting Procedures: Any student-athlete who is injured/becomes ill must IMMEDIATELY report the injury/illness to a member of the Mississippi State University Sports Medicine Department. Costs pertaining to an injury and/or illness not reported in a timely manner may be the responsibility of the student-athlete and/or his/her parent(s)/guardian(s). Missed Doctor s Appointment Policy: Student-athletes who are late and/or fail to show-up for scheduled appointments with the team physician, medical consultants, and/or diagnostic test/procedures will be financially responsible for any and all charges resulting from the missed appointment. In addition, the student-athlete may be responsible for rescheduling the appointment and providing his/her own transportation.

6 Contact Lens Policy: MSU Sports Medicine March 2015 Scholarship student-athletes in need of an eye exam and/or contact lenses will be referred to the Team Ophthalmologist/Optometrist by a member of the Mississippi State University Sports Medicine Department. If the doctor determines a need for contact lenses during sports participation, studentathletes will receive a supply of contact lenses. One (1) pair of lenses will be kept by the studentathlete s certified athletic trainer in case of an emergency. If the student-athlete has a current prescription, you are encouraged to transfer the prescription to one of our eye doctors. Your team s athletic trainer can help with that process, and the prescription must be less than one year old. Student-athletes in need of glasses need to contact the Compliance Office to determine if opportunity funds can be used to defray the expense. Out-of-town Physical Therapy/ Rehabilitation Procedures: At times, it may be necessary for a student-athlete to utilize an out-of-town physical therapy facility. In such situations, permission must be granted from the Director of Sports Medicine and/or her designee. Such referrals must come from a member of the Mississippi State University Sports Medicine Department. If a student-athlete decides to utilize physical therapy/rehabilitation services without the authorization of a member of the Mississippi State University Sports Medicine Department, the student-athlete and/or the student athlete s parent(s)/guardian(s) will be financially responsible for any and all medical bills incurred. Physician Referrals/Consultations: The Mississippi State University Athletic Department and MSU Sports Medicine have fostered positive relationships with many medical providers who have consistently provided high quality service to Mississippi State University student-athletes. Members of the Mississippi State University Sports Medicine Staff will refer student-athletes to these providers, unless extenuating circumstances necessitate a different provider. Student-athletes with HMO policies are strongly encouraged to have a local primary care physician (PCP), so that timely care can be given. All student-athletes must be seen and evaluated by a Mississippi State University certified athletic trainer before a referral to a physician will be made. A member of the Mississippi State University Sports Medicine Department must authorize and properly refer all student-athletes to see a physician or medical consultant, and/or for diagnostic tests. If a student-athlete decides to see a physician/medical consultant, and/or undergo a diagnostic test WITHOUT prior authorization/referral from a member of the Mississippi State University Sports Medicine Department, the student-athlete and/or the student athlete s parent(s)/guardian(s) will be financially responsible for any and all medical bills incurred. Medical Second Opinions: If a student-athlete and/or his/her parent(s)/guardian(s) desire another physician s opinion on a medical injury/illness, the student-athlete and/or the student athlete s parent(s)/ guardian(s) are financially responsible for any and all medical bills incurred, including but not limited to office visit charges, travel, and additional testing. The student-athlete will also be responsible for acquiring any requested medical records.

7 MSU Sports Medicine March 2015 Additional Information for Non-Scholarship/Walk-On Student-Athletes: All non-scholarship student-athletes are required to have coverage under a personal health insurance plan. The Mississippi State University Athletic Department will only take responsibility for injuries sustained while participating in a supervised workout, practice, game, or team travel and will not take responsibility for any expenses until your deductible has been reached. Any amount up to your deductible is the responsibility of the student-athlete and/or the parent(s)/guardian(s). For additional information, please review the Health Insurance Information that came with your Health Insurance Information/Authorization Form (separate mailing). KEEP THIS LETTER FOR YOUR RECORDS and direct any questions to: Mary McLendon, ATC Director of Sports Medicine (662) mkm13@msstate.edu

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10 MISSISSIPPI STATE UNIVERSITY STUDENT-ATHLETE HEALTH HISTORY Revised 7/16/03 Calendar Year TO BE COMPLETED BY STUDENT-ATHLETE (PLEASE PRINT CLEARLY) Name Sport Year at MSU: MSU# (9 digits) Marital Status Single Married Date of Birth Gender Male Female Local Address Ethnicity/Race City State Zip Cell Phone# Mother/ Guardian Home Phone # ( ) Address Work Phone # ( ) City State Zip Father/ Guardian Home Phone # ( ) Address Work Phone # ( ) City State Zip TO BE COMPLETED BY THE MSU MEDICAL STAFF Comments: Date of initial physical exam: Student-Athlete needs to be referred to: BP No indication from this questionnaire for referral to physician Orthopaedic General Medical Other Pulse Referred to: Referred to: Referred to: Athletic Trainer Signature, ATC Date, 20 Examination Date: Physician Name ( ) CLEARED TO PARTICIPATE ( ) PRIOR TO PARTICIPATING, STUDENT-ATHLETE REQUIRES: ( ) NOT CLEARED TO PARTICIPATE Physician Signature Date, 20 Examination Date: Physician Name ( ) CLEARED TO PARTICIPATE ( ) PRIOR TO PARTICIPATING, STUDENT-ATHLETE REQUIRES: ( ) NOT CLEARED TO PARTICIPATE Physician Signature Date, 20

11 MISSISSIPPI STATE UNIVERSITY STUDENT-ATHLETE HEALTH HISTORY STUDENT-ATHLETE S NAME This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The NCAA s policies recommend all student-athletes have a qualifying medical evaluation upon initial entrance into an institution s intercollegiate athletic program and an annual health-status review. Mississippi State University supports this NCAA policy. Further medical evaluations may be required for specific matters. NEW STUDENT-ATHLETES: If you have had a TDAP shot within the last 5 years, please provide: Date of last TDAP shot: _ / / Physician Signature or Clinic Stamp: Yes No Do you wear eyeglasses or contact lenses? (circle one or both) Date of Last Exam: Name and Phone Number for Prescriber: NEW STUDENT-ATHLETES: Have you ever had the following: RETURNING STUDENT-ATHLETES: In the past year have you had the following: If you answer Yes to any of the following, please provide a brief explanation and the date of the injury. 1. Yes No Major illness or hospitalization? 2. Yes No Illness lasting over 1 week? 3. Yes No Any operations or surgery? 4. Yes No Missing organs? (eye, kidney, testicle, etc.) 5. Yes No Allergy to any medication or food? 6. Yes No Problems with heart (i.e. heart murmur) or blood pressure? 7. Yes No Dizziness, fainting, frequent headaches, convulsions, or fatigue? 8. Yes No Shortness of breath or chest pain with exercise? 9. Yes No Dizziness, faintness, or headaches with exercise? 10. Yes No Heat exhaustion, heat stroke, or other heat problems? 11. Yes No Neck injury, head injury, concussion, or unconsciousness? 12. Yes No Knee injury, ankle injury, or surgeries? 13. Yes No Other serious joint injury, broken bones, or injury requiring a physician s treatment? 14. Yes No Do you wear any braces, dental bridges, or dental plates? 15. Yes No Do you currently have any incompletely healed injury? 16. Yes No Are you taking any medication on a regular basis? 17. Yes No Has any family member died suddenly at less than 40 years of age of causes other than an accident? Relation: 18. Yes No Has any family member had a heart attack at less than 55 years of age? Relation: 19. Yes No Has any family member been diagnosed with Marfan s Syndrome? Relation: 20. Yes No Has any family member had a problem with alcohol? Relation: 21. Yes No RETURNING ATHLETES ONLY: Would you like to discuss your current health with a team physician? The undersigned, herewith: A. Understands he/she must refrain from practice while ill or injured, whether or not receiving medical treatment, until discharged from treatment or given permission by the clinical practitioner to resume participation despite continuing treatment. B. Understands having passed the physical examination does not necessarily mean that he/she is physically qualified to engage in athletics, but only that the evaluation did not find a medical reason warranting disqualification at the time of said examination. C. Certifies the answers to the questions above are correct and true. Student-Athlete Signature Date

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14 NCAA Banned Drugs It is your responsibility to check with the appropriate or designated athletics staff before using any substance The NCAA bans the following classes of drugs: a. Stimulants b. Anabolic Agents c. Alcohol and Beta Blockers (banned for rifle only) d. Diuretics and Other Masking Agents e. Street Drugs f. Peptide Hormones and Analogues g. Anti-estrogens h. Beta-2 Agonists Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned drug class regardless of whether they have been specifically identified. Drugs and Procedures Subject to Restrictions: a. Blood Doping. b. Local Anesthetics (under some conditions). c. Manipulation of Urine Samples. d. Beta-2 Agonists permitted only by prescription and inhalation. e. Caffeine if concentrations in urine exceed 15 micrograms/ml. NCAA Nutritional/Dietary Supplements Warning: Before consuming any nutritional/dietary supplement product, review the product with the appropriate or designated athletics department staff! Dietary supplements are not well regulated and may cause a positive drug test result. Student-athletes have tested positive and lost their eligibility using dietary supplements. Many dietary supplements are contaminated with banned drugs not listed on the label. Any product containing a dietary supplement ingredient is taken at your own risk.

15 Note to Student-Athletes: There is no complete list of banned substances. Do not rely on this list to rule out any supplement ingredient. Check with your athletics department staff prior to using a supplement. Some Examples of NCAA Banned Substances in Each Drug Class Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); methylhexaneamine, bath salts (mephedrone) etc. exceptions: phenylephrine and pseudoephedrine are not banned. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): Androstenedione; boldenone; clenbuterol; DHEA (7-Keto); epi-trenbolone; etiocholanolone; methasterone; methandienone; nandrolone; norandrostenedione; stanozolol; stenbolone; testosterone; trenbolone; etc. Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC); synthetic cannabinoids (eg. spice, K2, JWH-018, JWH-073) Peptide Hormones and Analogues: growth hormone(hgh); human chorionic gonadotropin (hcg); erythropoietin (EPO); etc. Anti-Estrogens : anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene(ATD), etc. Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc. Additional examples of banned drugs can be found at Any substance that is chemically related to the class, even if it is not listed as an example, is also banned! Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center, REC, or password ncaa1, ncaa2 or ncaa3. It is your responsibility to check with the appropriate or designated athletics staff before using any substance. The National Collegiate Athletic Association June 2013 MEW

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17 NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment with Banned Stimulant Medication Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication. Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Drug Testing Exceptions Procedures at To be completed by the Institution: Institution Name: Institutional Representative Submitting Form: Name Title Phone Student-Athlete Name Student-Athlete Date of Birth To be completed by the Student-Athlete s Physician: Current Treating Physician (print name): Specialty: Office address Physician signature: Date Check off that documentation representing each of the items below is attached to this report o Diagnosis. o Medication(s) and dosage. o Blood pressure and pulse readings and comments. o Note that alternative non-banned medications have been considered, and comments. o Follow-up orders. o Date of clinical evaluation: o Attach written report summary of comprehensive clinical evaluation. Please note that this includes the original clinical notes of the diagnostic evaluation. The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores. The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

18 MSU SPORTS MEDICINE STUDENT-ATHLETE CONCUSSION STATEMENT (To be signed annually) August 1 st, 2010 Revised August 2011 September 2013 I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician. I have read and understand the NCAA Concussion Fact Sheet. After reading the NCAA Concussion Fact Sheet, I am aware of the following information: Initial Initial Initial A concussion is a brain injury, which I am responsible for reporting to my physician or athletic trainer. 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. Common signs and symptoms of a concussion include: Initial - Amnesia - Confusion - Headache - Loss of consciousness - Nausea - Double or fuzzy vision - Sensitivity to light or noise - Balance problems or dizziness - Feeling unusually irritable - Feeling sluggish, foggy, or groggy - Slowed reaction time - Concentration or memory problems If I experience any of these signs or symptoms or in any way suspect I have suffered a concussion, I am responsible for reporting this to my team physician or athletic trainer. Initial Initial Initial Initial If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer. 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. I understand I am much more likely to have a repeat concussion if I return to play before my symptoms resolve. I understand repeat concussions can cause permanent brain damage and even death. PRINT NAME SIGNATURE DATE SIGNATURE OF PARENT OR GUARDIAN IF UNDER 18

19 CONCUSSION A FACT SHEET FOR STUDENT-ATHLETES WHAT IS A CONCUSSION? A concussion is a brain injury that: Can happen even if you do not lose consciousness. HOW CAN I PREVENT A CONCUSSION? Basic steps you can take to protect yourself from concussion: WHAT ARE THE SYMPTOMS OF A CONCUSSION? WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don t hide it.. Report it. Get checked out. Take time to recover. IT S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON. WHEN IN DOUBT, GET CHECKED OUT. Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.

20 MSU Sports Medicine Revised April 2015 MISSISSIPPI STATE UNIVERSITY FEMALE ATHLETE HEALTH HISTORY This form should be completed and signed by the athlete prior to her physical examination. All answers are confidential within the Sports Medicine team. Menstrual Health 1. At what age did you begin competitive training for your sport? years old 2. How old were you when you had your first menstrual period? years old 3. How often do you have your period? Every days 4. How long do your periods last? days 5. How many periods have you had in the last 12 months? 6. When was your last period? / / 7. Do you ever have trouble with heavy bleeding? Yes No 8. Do you ever experience cramps during your period? How do you treat them? Yes No 9. Do you take birth control pills or hormones? Name of the prescription? Yes No 10. Have you ever been pregnant? Yes No 11. Do you have any unusual vaginal discharge? Yes No 12. Have you ever had a pelvic exam/ pap? Date of your most recent pelvic exam? Yes No / / 13. Have you ever had an abnormal pap smear? Yes No 14. How many urinary tract infections (bladder or kidney) have you had? Nutrition 15. Have you ever been treated for anemia? Yes No 16. How many meals do you eat each day including snacks? 17. How do you rate your diet? Excellent Good Fair Poor 18. Are you on a special diet or do you avoid certain types of foods or food groups? (e.g. meats, bread)? 19. List everything you have eaten in the last 24 hours 20. Have you ever been on a weight loss diet? Yes No 21. What is your current Height? Weight? Dress size? ft. in./ lbs./ Clothing size 22. How much of an issue for you is your weight? 23. Do you consciously watch your weight for your sport? Yes No 24. Are you preoccupied with thinking about food during the season? Yes No 25. How often are you dieting during the season? 25. Are you trying to gain or lose weight? Gain Lose Neither 26. Are you happy with your present weight? If not, what would you like to weigh? Yes No lbs. 25. Has anyone recommended that you gain or lose weight? Yes No Who? 27. Do you have any questions about healthy ways to control weight? Yes No

21 MSU Sports Medicine Revised April Have you ever tried to control your weight by vomiting? Yes No fasting? Yes No using laxatives? Yes No using diuretics? Yes No using diet pills? Yes No 33. Have you ever eaten a large amount of food rapidly and felt that this eating incident was excessive and out of control (aside from holiday feasts)? How often has this happened in the past year? Yes No times 34. Do you feel like you lose control of yourself when eating? Yes No 36. Have you ever been diagnosed as having an eating disorder? Yes No General Health 35. Do you often exercise in addition to your team workouts? Yes No 36. Have you ever had a stress fracture? If yes, please list the location(s) Yes No 36. Have you ever been told you have low bone density (osteopenia or osteoporosis)? Yes No 37. List any questions you may have about medications, diet, weight gain/loss, or any other health matters: Use this space to explain any of the above YES answers and to provide any additional information; a second page may be used. Question # Comments Signature of Athlete / / Date Print Name Signature of MSU Athletic Trainer / / Date