All forms are to be completed and returned to: The University of Denver Attn: Sports Medicine, Room E. Asbury Ave. Denver, CO

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1 Julie Campbell Director of Sports Medicine (303) Office (303) Fax To: Re: Returning Student-Athletes Sports Medicine Medical Information Packets Date: Thursday, May 15, 2014 As in previous years, in order to be eligible for participation in intercollegiate athletics at the University of Denver, it is necessary to update your medical information on a yearly basis. Attached is the returning questionnaire, which needs to be completed and returned with a copy of your insurance card, preferably before you depart for summer break. If additional time is necessary to complete the required information, please do so and return the forms to us by July 15, Please take the time to accurately complete all forms, insuring that all of the updated information is correct. You will be expected to have a brief health screening in the fall prior to your return to practice. Your coach will contact you with the scheduled dates and times for this mandatory medical screening. Feel free to contact us with any questions at or visit the website at and click on the Sports Medicine link. All forms are to be completed and returned to: The University of Denver Attn: Sports Medicine, Room E. Asbury Ave. Denver, CO

2 University of Denver Sports Medicine Medical Questionnaire Returning Athletes Name: Last First Middle Sport Annual Screening Height (COMPLETED BY SPORTS MEDICINE STAFF) Weight lbs Blood Pressure (1) / (2) / (3) / Date Date Pulse bpm Vision: Corrected Uncorrected Right 20/ Left 20/ Please fill out the following questionnaire for any injuries that you have incurred over THE LAST 12 MONTHS ONLY. Please include any injuries considered chronic or injuries that are not healed at this time. Concussion or Head Injuries: Yes Date Neck Injuries: Yes Left Right Date Shoulder Injuries: Yes Left Right Date Upper arm, Elbow, and Forearm: Yes Left Right Date Wrist Injuries: Yes Left Right Date 2

3 Hand or Finger Injuries: Yes Left Right Date Back Injuries: Yes Left Right Date Rib/Chest Injuries: Yes Left Right Date Hip or Thigh Injuries: Yes Left Right Date Knee Injuries: Yes Left Right Date Lower Leg Injuries: Yes Left Right Date Ankle Injuries: Yes Left Right Date Foot Injuries: Yes Left Right Date 3

4 PLEASE INDICATE IF ANY OF THE FOLLOWING PERTAIN TO YOU YES NO Glasses Do you wear them for sports? Contact Lenses Do you wear them for sports? YES NO Have you ever been diagnosed with ADD/ADHD? If so, when tested? By whom? Are you currently taking medication(s) for ADD/ADHD? If so, which medications? Do you take any medicines regularly? If yes, which medications and for what conditions? (Include: Birth control, insulin, allergy shots/pills, asthma inhalers, anti-depressants, vitamin or mineral supplements, ADD/ADHD, anti-inflammatories, and or any supplements) PLEASE INDICATE IF ANY OF THE FOLLOWING PERTAIN TO YOU YES NO Allergies If yes, to what? Migraines Current Medications: Hay Fever Current Medications: Asthma Current Medications: High or Low Blood Pressure Current Medications: Epilepsy Current Medications: Sickle Cell Anemia/Trait Current Medications: Leg Cramps Current Medications: Stomach Ulcers Current Medications: Diabetes Current Medications: Mental Health Condition (depression, anxiety, eating disorder, etc.) If yes, please list condition: Current Medications: Mononucleosis (mono) *within the past 3 months 4

5 Dental/Oral surgery (wisdom teeth removal) *within the past 3 months Do you feel you need to see a physician prior to competition? Please address any concerns you may have, which were not addressed in the above questions: The above statements are true to the best of my knowledge. This athlete gives consent to the team physicians, consulting physician, and/or appropriate member of the Sports Medicine staff at the University of Denver to examine records, or be in consultation concerning examination or participation in any varsity athletic program at the University of Denver. The athlete also gives permission to acceptable diagnostic, therapeutic, and emergency operative procedures to be carried out in the treatment of illness and/or injury sustained while a member of the University of Denver varsity athletic teams. Signature: Date: If under 18, Parent or Guardian Signature: 5

6 Medical Treatment Consent Form The individual named below as Student-Athlete, if over the age of 18, hereby consents, or his parent or legal guardian if the Student-Athlete is under the age of 18 hereby consents, to the provision and/or obtainment of medical treatment and/or care as deemed necessary by the University of Denver (Colorado Seminary) and it s Division of Athletics and Recreation Department of Sports Medicine staff for the health and well-being of the Student-Athlete during the term of his/her participation in University of Denver athletics, including the consent to obtain and have administered any routine, diagnostic or emergency medical or surgical treatment, including examination, X-ray, anesthetic or hospital care, recommended by any physician licensed to practice medicine. The undersigned further agrees to release, hold harmless and indemnify the University of Denver, Division of Athletics and Recreation, staff, coaches, and athletic trainers from any claims, demands, suits, or damages from any injury or complications which may result from the provision of medical treatment or care to the Student-Athlete. Student-Athlete Signature: Date: If under 18, Parent or Guardian Signature: Medical Information Release The individual named below as Student-Athlete, if over the age of 18, hereby authorizes, or his parent or legal guardian if the Student-Athlete is under the age of 18 hereby authorizes, the University of Denver Health and Counseling Center, and/or treating physicians (University physician or personal physician) to release any x-rays, reports, medical history records, laboratory records, diagnosis, and other data to the Department of Sports Medicine staff as they deem necessary during the term of Student-Athlete s participation in athletics at the University of Denver. The undersigned hereby authorize any insurance company, hospital, physician, and/or any other provider who has attended or examined the Student-Athlete to disclose when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A photostatic copy of this authorization shall be considered as effective and valid as the original. Student-Athlete Signature: Date: If under 18, Parent or Guardian Signature: 6

7 University of Denver Division of Athletics and Recreation Acknowledgement and Assumption of Risk and Release THIS DOCUMENT MUST BE SIGNED BY THE PARENT OR LEGAL GUARDIAN OF PERSONS UNDER THE AGE OF 18 PARTICIPATING IN ANY PROGRAM HELD UNDER THE AUSPICES OF COLORADO SEMINARY WHICH OWNS AND OPERATES THE UNIVERSITY OF DENVER (COLLECTIVELY UNIVERSITY OF DENVER ). IF THE PERSON PARTICIPATING IN THE PROGRAM IS 18 YEARS OF AGE OR OLDER, THEN THE STUDENT-ATHLETE MUST SIGN THIS DOCUMENT. * * * The University of Denver strives to provide a safe environment for its Student-Athletes, through measures such as providing awareness and guidance on risk of injury and injury prevention. However, it is important for the Student-Athlete (or his parent or legal guardian if the Student- Athlete is under 18), to understand that even with such safety measures, participation in intercollegiate athletics involves unavoidable exposure to an inherent risk of injury. Therefore, the individual named below as Student-Athlete, if over the age of 18, hereby agrees, or his parent or legal guardian if the Student-Athlete is under the age of 18 hereby acknowledges that he or she authorizes Student-Athlete, to participate in the University of Denver s Intercollegiate Athletic Program (the Program ), and further acknowledges his or her full understanding and appreciation that there are risks of injury associated with participation in the Program. These risks include, but are not limited to, injuries sustained from falling, reasonable sport-appropriate contact with another student-athlete or overexertion. These risks occur in activities including, but are not limited to, training, practice, games, tournaments, competitions, exhibitions, on-field celebratory behavior and travel to and from games or other University of Denver Athletic Program sponsored activities. The person signing this document hereby represents that he or she has advised the University of Denver of any facts known to him or her which would make the Student-Athlete more susceptible to injury or risk of injury as a result of participating in the Program than would be the average person of the same age. Any parent or legal guardian signing further represents that he or she has thoroughly explained to the minor Student-Athlete the risks associated with participating in the Program using language appropriate to the age and intellectual capacity of the Student-Athlete. By signing this form, the Student-Athlete, or his parent or legal guardian, on behalf of himself, his heirs, assigns, legal and personal representative(s), agrees to assume all risks and responsibilities surrounding Student-Athlete s participation in the Program and further to release the University of Denver, and all departments and divisions thereof from any claims, demands, actions, causes of action, lawsuits, expenses, or losses (including court costs and all reasonable attorney fees) he or she may have on account of personal injury (including death) arising out of or attributable to Student-Athlete s participation in the Program, unless such personal injury or death is caused by the negligence of University of Denver, its trustees, employees or agents. PRINTED NAME OF STUDENT-ATHLETE SIGNATURE OF STUDENT-ATHLETE IF STUDENT-ATHLETE IS UNDER 18 YEARS OF AGE: PRINTED NAME OF STUDENT-ATHLETE S PARENT OR LEGAL GUARDIAN SIGNATURE OF STUDENT-ATHLETE S PARENT OR LEGAL GUARDIAN 7

8 OUT-OF-NETWORK INSURANCE POLICY & INTERNATIONAL INSURANCE POLICY INFORMATION Student-athletes who have out-of-network health insurance policies have often found that their policies do not provide necessary and/or adequate coverage for injuries or illness treated in Denver. In order to provide adequate insurance for your son/daughter in the event of an injury or illness, we strongly recommend that you contact your insurance company in order to arrange for out of network coverage while your son/daughter is attending the University of Denver. 1. Is your son/daughter s primary insurance an International Insurance Policy? (please circle one) YES NO If YES, please proceed to question #2. If NO, please proceed to page What is the current United States phone number and address for claims under this policy? Phone: ( ) - Address: In order to comply with DU policy, you must provide a phone number and address within the United States for claims. International insurance without this claim information will not be accepted. You will need to show proof of medical insurance that is either a US company or possesses a US address for claims. 8

9 UNIVERSITY OF DENVER SPORTS MEDICINE 2014/2015 HEALTH INSURANCE INFORMATION FORM (Please Print Clearly) ***PLEASE ATTACH COPY OF FRONT AND BACK OF INSURANCE CARD*** Athlete's Name (Print) Sport Student s Local/Campus Mailing Address City, State, Zip Cell Phone Number ( ) Address Date of Birth / / SS # - - DU Student ID# Parent or Guardian Information Father's Name Date of Birth / / SS # - - a Home Address Home Phone ( ) City, State, Zip Employer Cell Phone ( ) Mother's Name Date of Birth / / SS # - - a Address Home Phone ( ) City, State, Zip Employer Cell Phone ( ) Under whose policy is dependent son/daughter covered? Father Mother Guardian Own Please complete the following information for that insurance policy: Insurance Co. Phone # ( ) Send Claims Address (BACK OF CARD): City, State, Zip: Policy or ID #: Group #: Plan (HMO, PPO, etc.): Does your insurance plan require pre-authorization for treatment? Yes Effective Date: Telephone number for pre-authorization: ( ) Dental Insurance Carrier: Policy. Address Phone ( ) Signature of Athlete / If under 18, Signature of Parent/Guardian Date 9

10 Stimulant Medication Use for the Treatment of ADHD This letter is to inform you of recent changes by the NCAA regarding the use of ADHD medicine by student-athletes. If you are currently taking medication you MUST read this letter as your eligibility and future athletic career are involved! The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in competition. Some legitimate medications contain NCAA banned substances, and student-athletes may need to use these medicines to support their academics and their general health. The NCAA has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The NCAA allows exceptions to be made for those student-athletes with a documented medical history demonstrating the need for regular use of such a drug. The benefit of a medical exception procedure is that in most cases the student-athlete s eligibility remains intact during the process. The most common medications used to treat ADHD are methylphenidate (Ritalin) and amphetamine (Adderall), which are banned under the NCAA class of stimulants. In order for a medical exception to be granted for the use of these stimulant medications, the student-athlete must show that he or she has undergone standard assessment and testing to identify ADHD. Frequently a student-athlete may find that the demands of college present difficult learning challenges. They may realize that some of their teammates are benefitting from the use of these medications, and figure they should ask their team physician or family doctor to prescribe the same for them. If they do not undergo a standard assessment and testing to diagnose ADHD, they have not met the requirements for an NCAA medical exception and will not be cleared for athletic participation. Due to concerns about the abuse of ADHD medication the NCAA will require more information in file to allow for the appropriate medical use. This stricter application will require documentation that demonstrates the student-athlete has undergone a clinical assessment to diagnose ADHD, is being monitored routinely for use of the stimulant medication, and has a current prescription on file, in order to be approved for a medical exception to the banned drug policy. This documentation should be kept on file at the institution and produced in the event the student-athlete tests positive for the banned medication. Without the proper documentation already on file, a student-athlete that tests positive for stimulant use, even if medically appropriate, could possible lose a year of eligibility! To prevent this from happening, the sports medicine staff will not clear a student-athlete for fall practice if we know they are taking Ritalin or Adderall AND do not have the appropriate documentation on file. 10

11 In order for a student-athlete to be granted a medical exception for the use of a medication that contains a banned substance, the student-athlete must provide documentation from the prescribing physician to the Sports Medicine staff. This documentation should contain a minimum of the following information to help ensure that ADHD has been diagnosed and is being managed appropriately: a. Description of the evaluation process that identifies the assessment tools and procedures. b. Statement of the Diagnosis, including when it was confirmed. c. History of ADHD treatment (previous/ongoing). d. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed. e. Statement regarding follow-up and monitoring visits. Please be aware that it is ultimately the responsibility of each individual student-athlete to provide the necessary documentation. Please contact Julie Campbell at julie.campbell@du.edu or if you are taking any ADHD medication so we can provide you with the necessary form and help guide this process. You can also find the form on the Denver Pioneers website under the INSIDE DU & the SPORTS MEDICINE link: 11