2014-2015 New Athletes

Dear New Student-Athlete, 2014-2015 New Athletes Prior to participating on a Northeastern University athletic team, athletes must provide the Athletic Department with their current address, emergency contact information, insurance, medical alerts, and health history information. To expedite this process, the University uses SportsWare, an online data entry system compliant with the Health Insurance Portability and Accountability Act (HIPAA), where all of your personal information is securely located. Please find directions below. *Note: If you are trying out for a team, the online database is not available. Please print and fill out all information linked to "Try out Forms" on www.gonu.com/medforms In addition to the printed information from SportsWare, additional waivers and insurance information are required. Please read and sign all included waivers in this printout, the insurance page, provide a copy of both sides of your insurance card, and mail them along with the printouts from SportsWare by July 1, 2014 to: Northeastern University Sports Medicine 360 Huntington Avenue 219 Cabot Center Boston, MA 02115 ATTN: Medical Clearance *Note: New Athletes will need to send a copy of their most recent doctor s physical along with the other required paperwork. The form for your physician to fill out is at the end of this packet. If you have any questions please contact the Sports Medicine Department at 617-373-8221 for assistance or email m.mckenney@neu.edu (Check box when completed) 1. My Info and Med History print outs from SportsWare. a. Update and print out from SportsWare. www.swol123.net b. Directions for SportsWare can be found at www.gonu.com/medforms 2. Completed and signed New Athlete Waivers a. Included in this packet 3. Completed and signed Insurance Form a. Included in this packet 4. Photocopy s of both sides of your current insurance card a. Attach copy to Insurance Form 5. Completed and Signed Doctor s Physical a. Must be signed and completed by your doctor b. This form is included in this packet. Any Questions, please contact the Sports Medicine Department at 617-373-8221

Go to https://www.swol123.net/ To log in to the system: Enter your personal email that is used to communicate with coaches. (Ex: johndoe@gmail.com) Select RESET PASSWORD to set your initial Password. You will get an email with a link that allows you to customize your password. Contact Sports Medicine Department with any problems Enter your email and password and click login Select My Info at top of screen and complete all tabs inside. Click Save.

Select Med History at top of screen and fully complete questionnaire. Click Save. Click Print Tab at home and print both My Info and Med History. Print 2 copies: one for your own records and mail one copy along with your waivers to Northeastern University Sports Medicine 360 Huntington Ave 219 Cabot Center Boston, MA, 02115 Attn: Medical Clearance

Primary Insurance Coverage The Sports Performance Department along with University Health and Counseling Services encourage all student-athletes to consider purchasing the Northeastern University Student Health Plan (NUSHP) as a way to ensure appropriate coverage for both athletic and NON-athletic injury and illness, while ensuring the most expeditious processing of diagnostic testing and procedures should an injury or illness occur. NUSHP is administered by Blue Cross Blue Shield of Massachusetts and provides extremely comprehensive health benefits at a very affordable rate. In fact, our students often tell us this plan is better than others available through their family's employers. NUSHP is accepted by all Blue Cross Blue Shield participating providers throughout the United States. When enrolled in NUSHP, no prior authorizations are needed because it is a PPO Plan. We often hear from providers, they like to see when a student has NUSHP because it means they know that it provides comprehensive coverage with administrative ease. For complete information, please see www.northeastern.edu/nushp. As primary insurance coverage, all medical expenses incurred will first be processed through NUSHP. Northeastern University also carries an Excess Sports Accident Insurance policy which covers most expenses beyond your primary insurance coverage for athletic related accidents and injuries, up to 100% of usual and customary charges. If a student becomes ill or injured (example: appendicitis or bicycle accident) NOT related to athletic participation, NUSHP will provide coverage. **Nothing in this communication may be construed to constitute a promise of benefits from Northeastern University's Student Health Plan. Only Blue Cross Blue Shield of Massachusetts can provide a pre-determination of benefits.** I,, fully understand both the limitations and benefits of my current primary insurance coverage as it relates to both athletic and non-athletic related injuries. Printed Name Signature of Parent/Guardian if Student-Athlete is Under 18 Years of Age Signature Date

Health Insurance Information for 2014-2015 Academic Year Athlete s Name M / F Last First MI (Circle) Athlete s Home Address City State Zip Code Home Phone Number Cell phone NU #. Does your insurance plan have a deductible? How much? Does your insurance plan require a co-pay for services and/or prescriptions? Sport(s) Athlete s DOB / /. Complete Name of Primary Insurance Company Insurance Address Policy Holder s Name Last First MI Policy Holder s Address City State Zip Code Does this insurance company require precertification for the following services? X-rays MRI Hospital Admission Consultation outside of Network Other: please list Policy Holder s DOB / /. Please copy the front and back of your primary insurance card and affix it below. Front Back

ONLY COMPLETE THIS PAGE IF YOU WISH TO UTILIZE OR HAVE A SECONDARY INSURANCE POLICY Complete Name of Secondary Insurance Company (if applicable) Does your insurance plan have a deductible? How much? Insurance Address Does your insurance plan require a co-pay for services and/or prescriptions? Policy Holder s Name Last First MI Policy Holder s Address Number Street Policy Holder s DOB / /. City State Zip Code Does this insurance company require precertification for the following services? X-rays MRI Hospital Admission Consultation outside of Network Other: please list Please copy the front and back of your secondary insurance card and affix it below. Front Back PRE-PARTICIPATION EXAMINATION Statement: The National Collegiate Athletic Association s (NCAA) policies recommend that all student-athletes have a qualifying medical evaluation upon their initial entrance into an institution s intercollegiate athletic program. Northeastern University adheres to the NCAA policy. Further evaluation (subsequent to the initial qualifying exam) may be necessary in specific cases. A preparticipation history update will be performed annually and physical examination if indicated. Northeastern University

Sickle Cell Trait Information Sheet and Waiver In April of 2010, the NCAA Division I Legislative Council decided that all Division I student athletes must be tested for the sickle cell trait, provide proof of a prior test, or sign a waiver, releasing an institution from liability if a Student-athlete opts not to be tested or provide proof of an earlier status test. This new rule is effective beginning with the 2010-2011 academic year. Northeastern University is supportive of this decision and requests that student-athletes provide Sports Medicine with appropriate documentation of their sickle cell trait status. If student-athletes do not know their status, it is recommended they undergo testing to determine whether they are positive for the sickle cell trait. If a student chooses not to provide the requested information to Sports Medicine or not to be tested, he/she must sign the waiver/release below. In order to assist you in making an informed decision regarding this issue, general information about sickle cell trait follows below. Sickle Cell Sickle Cell is a genetic disorder of the blood that causes the body to produce hard, sickle-shaped red blood cells that can block blood vessels and starve the body of oxygen. There are approximately over 72, 000 Americans with sickle cell disease and over 2 million Americans who carry the sickle cell trait. While sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American Ancestry, persons of all ancestries and races may test positive for sickle cell trait. Sickle cell trait is generally benign, but during intense, sustained exercise lack of oxygen in the muscles may cause the sickling of red blood cells (red blood cells change from the typical disc shape into a sickle or crescent shape). The sickle-shaped cells can accumulate in the bloodstream, blocking blood vessels. This can lead to collapse and/or even death due to a rapid breakdown of muscles starved of blood. Other problems associated with sickle cell trait may include increased urinary tract infections in women, blood in urine, and exertional heat and/or altitude illnesses. More information about sickle cell trait and the NCAA s decision may be found at www.ncaa.org. Testing for Sickle Cell Trait Northeastern and the NCAA recommend that all student-athletes know their sickle cell trait status. Testing can be conducted at University Health and Counseling Services or through a physician or laboratory facility of your own choosing. If you choose to undergo testing, all associated costs are your own responsibility. Appropriate documentation of sickle cell trait status must be provided prior to any athletic participation. If you choose not to be tested or not to provide appropriate documentation of your sickle cell trait status, you must complete the waiver/release below. The waiver/release must be completed prior to any athletic participation. I,, understand and acknowledge that the NCAA and Northeastern University recommend that all student-athletes have knowledge of their sickle cell trait status. In addition, I have read, acknowledge and understand all of the above provided information about sickle cell trait and testing and the NCAA and Northeastern recommendations. By signing this waiver and release, I confirm that I do not wish to undergo sickle cell trait testing and/or to provide appropriate medical documentation of my sickle cell trait status to Northeastern University. By signing this waiver/release, I voluntarily and forever release, discharge, hold harmless and indemnify Northeastern University, its trustees, officers, faculty, employees, students, and agents from any and all costs, liabilities, claims, expenses, demands, or causes of action on account of any loss or injury or death that may result or in any way be caused, related or connected to my decision not to follow the recommendations of the NCAA and Northeastern University and/or my decision not to undergo testing to determine my sickle cell trait status and/or to provide my status information to Northeastern University. I have read and signed this document with full knowledge and comprehension of its significance. Printed name of Student-Athlete: Signature of Student-Athlete: Date: If Student-Athlete is a minor: As the parent/guardian of the above-named student athlete, I have read, understand and agree to the above: Parent/Guardian signature: Date:

Pre Participation Examination The undersigned here within, A. Understands that I must refrain from practice or play while ill or injured whether or not receiving treatment until I am discharged from treatment or given permission by the health care provider to restart participation despite continuing treatment. B. Understands that passing the physical examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify me at the time of said exam. C. Acknowledges that ALL questions on this form have been answered completely and truthfully to the best of my knowledge. Printed name of Student-Athlete: Signature of Student-Athlete: Date: As the parent/guardian of the above-named athlete, I agree to the Team Physician Clearance statement: Parent/Guardian signature (if Student-Athlete is a minor): Date: Assumption of Risk Injury is an inherent aspect of sport. I understand that through my participation in the intercollegiate athletic program at Northeastern University I am subject to the possibility of injury, and also understand that by my participation, I accept the risk of possible injury. I understand that those who are responsible for the conduct of my sport have taken reasonable precautions to minimize such risks. This statement will remain in effect until such time as it is revoked in writing. Printed Name Signature of Parent/Guardian if Student-Athlete is Under 18 Years of Age Signature Date

AUTHORIZATION FOR RELEASE OF MEDICAL/PERSONAL INFORMATION: I,, authorize Northeastern University and its employees and representatives to release pertinent (Student printed name) personal and insurance information to any interested medical care provider and the coach of my sport. This information may need to be provided to interested persons in the event that I require medical care. This information may include, but is not limited to: my name, date of birth, social security number, insurance information, parent s telephone numbers, school and home addresses and emergency contacts. I also authorize Northeastern University and any physician, certified athletic trainer or other health care provider retained by Northeastern University to release and discuss with the coach of my athletic team, the Northeastern University athletic administration or any interested health care provider, information concerning my past and present general health, provided that Northeastern University or any such health care provider has determined in its, his or her sole discretion that such information may be relevant to my ability to participate, or continue to participate, in any Northeastern University athletic program. For good and valuable consideration, the receipt of which is hereby acknowledged, I release Northeastern University (including its offices, trustees, employees, agents and representatives) from any and all claims and liability arising from the release by Northeastern University or my medical records or other personal information in accordance with the terms of the foregoing authorization. Student-Athlete signature: Date: I,, the parent/guardian (if student is a minor) of the above-named student-athlete agree to the Authorization for release of medical/personal information for my son/daughter. Parent/guardian signature (if Student-Athlete is a minor): Date: Required Immunization Documentation All incoming Northeastern University STUDENTS are required to have up-to-date immunization records on file with the University Health and Counseling Services (UHCS) office. A student will have a Health Center hold if the student has failed to provide complete documentation of immunizations in accordance with Massachusetts state law. Deadline for providing this information are as follows: *The end of June for undergraduate students entering in the following Fall; *The beginning of December for undergraduate students entering in the following Spring; *One month prior to the beginning of a Graduate student or Law student s program. Health Center holds will prevent a student from registering themselves for an upcoming semester. The Health Center hold also will prevent a student's ability to complete "I Am Here. For questions about holds due to state mandated immunity requirements, please cell 617-373-2772 or email UHCS general email box at UHCS@neu.edu. This form is separate from the documentation required of STUDENT-ATHLETES and is required by ALL STUDENTS and is to be submitted directly to UHCS. A student at Northeastern University must provide the Health Center with proof of immunity to certain diseases, as specified below. Documentation of immunizations and/or titers must be on the University's Health Report, or a clinician s letterhead or prescription slip, signed by a nurse, nurse practitioner, or physician assistant. Alternatively, documentation may be provided by the student's high school, previous college, or military facility, again with clinician signature. Required Immunizations: 2 MMR, Tetanus/Diphtheria/Pertussis, Hepatitis B, Varicella/Chicken Pox, and Meningitis (or signed waiver) I,, understand and acknowledge the above statement and comprehend its significance. Printed name of Student-Athlete: Signature of Student-Athlete: Date: As the parent/guardian of the above-named athlete, I agree to the Required Immunization Documentation statement: Parent/Guardian signature (if Student-Athlete is a minor): Date:

Medication Administration The Northeastern University Sports Medicine Department has Non-Prescription oral medications available for Student athletes as needed per Sports Medicine staff recommendations as supervised directly by Team Physician. These medications can be purchased over the counter at supermarkets and pharmacies. These medications can be requested by student-athletes and are administered at the discretion of the sports medicine staff. I,, understand and acknowledge the above statement and comprehend its significance. Printed name of Student-Athlete: Signature of Student-Athlete: Date: As the parent/guardian of the above-named athlete, I agree to the Medication Administration statement: Parent/Guardian signature (if Student-Athlete is a minor): Date: Intercollegiate Athletic Participation by the Pregnant Student-Athlete Females Only I understand that if during my athletic career at Northeastern University I become pregnant that I will inform the Sports Medicine Department immediately. I understand that if I do not inform the sports medicine department there is potential to have labor and birth complications, damage or loss of the unborn fetus, and potential health complications to myself. I am fully aware of the potential consequences, and I accept and assume liability if injury were to occur as a result of participating in intercollegiate sports for Northeastern University. Furthermore, I agree to follow all safety precautions and will discontinue participation as recommended by the Northeastern University Sports Medicine staff. I hereby release and indemnify Northeastern University, its trustees, officers, agents, physicians and sports medicine staff, coaches, and employees from all suits, claims, or causes of action related to my potential condition. This statement will remain in effect until revoked in writing. I,, understand and acknowledge the above statement and comprehend its significance. Printed name of Student-Athlete: Signature of Student-Athlete: Date: As the parent/guardian of the above-named athlete, I agree to the Intercollegiate Athletic Participation by the Pregnant Student Athlete statement: Parent/Guardian signature (if Student-Athlete is a minor): Date:

Consent to Treat I hereby authorize the Certified Athletic Trainers and sports medicine staff to evaluate and treat any injury/illness that occurs during my participation in intercollegiate athletics at Northeastern University. I understand and agree that if I experience an injury/illness that it is my responsibility to inform the Sports Medicine Department or Certified Athletic Trainer who is coordinating my care. While under the medical care of Northeastern University s Sports Medicine Department an athlete may not return to participation until they have been medically cleared by either a Northeastern Certified Athletic Trainer or the Team Physician. I,, understand and acknowledge the above statement and comprehend its significance. Printed name of Student-Athlete: Signature of Student-Athlete: Date: As the parent/guardian of the above-named athlete, I agree to the Consent to Treat statement: Parent/Guardian signature (if Student-Athlete is a minor): Date: Authorization for Release of Medical Information from UHCS I hereby authorize the Northeastern University Sports Medicine Staff to access my medical records at the University Health and Counseling Services in circumstances where the records pertain to and/or affect my intercollegiate athletic participation status. Student-Athlete signature: Date: I,, the parent/guardian (if student is a minor) of the above-named student-athlete agree to the Authorization for release of Medical information from UHCS for my son/daughter. Parent/guardian signature (if Student-Athlete is a minor): Date:

TEAM PHYSICIAN CLEARANCE As a current or prospective student-athlete at Northeastern University, I understand and agree to the following statement: The Athletic Department of Northeastern University has a designated Team Physician(s). The physician has final approval or disapproval of my participation in intercollegiate athletics at Northeastern University. This includes, but is not limited to the following: pre-participation exam results and illness or injury prior to, during and post season. This decision may be in lieu of or in addition to recommendations by other physicians. Printed name of Student-Athlete: Signature of Student-Athlete: Date: As the parent/guardian of the above-named athlete, I agree to the Team Physician Clearance statement: Parent/Guardian signature (if Student-Athlete is a minor): Date:

NCAA Drug Testing Exception Policy Use of Stimulants to Treat ADD/ADHD Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) are common neurobehavioral disorders of childhood that can persist through adolescence and into adulthood. The most common medications used to treat ADD/ADHD are methylphenidate (Ritalin) and amphetamine (Adderall); both are banned under the NCAA class of stimulants. Recently, the NCAA has updated their policy regarding medical exceptions of banned drug classes. The NCAA bans performance enhancing drugs to protect the health and safety of student-athletes, and to ensure a level playing field. The NCAA also recognizes that some of these substances may be legitimately used as medication to treat student-athletes with learning disabilities and other medical conditions. The current policy can be found at: www.ncaa.org/health-safety. To be considered for medical exception for a medication that contains a banned substance, the student-athlete must provide the required documentation from the prescribing physician: Documentation of the diagnosis and how it was reached through diagnostic testing Documentation of the treatment procedure, name of medication and dosage information and a copy of the current prescription Statement that the student-athlete s medical history exhibits a need for regular use of the drug List of alternative non-banned medications for the treatment of the condition that have been tried/considered Statement that the student-athlete and prescribing physician agree that there is no other appropriate alternative medication treatment available **Starting in August 2009, all student-athletes are required to have this documentation on file with the Northeastern University Sports Medicine staff prior to the start of the athletic year.** ---------------------------------------------------------------------------------------------------------------------------------------------------------- Please answer the following question(s), initial and sign below: Have you been diagnosed as having ADD/ADHD? YES / NO If yes: Are you currently on medication(s) for treatment of ADD/ADHD? YES / NO If yes, please fill out table below: Medications Dose Prescribing Physician I have been informed of the NCAA drug testing exception using stimulants to treat ADD/ADHD. I understand that I am responsible for notifying the Sports Medicine staff and the Athletic Department representative for compliance with regard to my current medical status and need for any NCAA drug testing medical exception. I understand that it is my responsibility to provide the Northeastern University Sports Medicine Department with all required documentation related to the treatment of my condition Student-Athlete Signature DATE: Signature of Parent/Guardian if Student-Athlete is Under 18 Years of Age DATE:

NORTHEASTERN UNIVERSITY DEPARTMENT OF ATHLETICS FERPA Authorization for Release of Health Information for Varsity Intercollegiate Athletes Name (Please Print) Sport Date of Birth NU ID Number TO: NORTHEASTERN UNIVERSITY ATHLETIC TRAINERS, PHYSICIANS, STRENGTH COACHES, SPORTS DIETICIANS AND OTHER RELATED PERSONNEL: You are hereby authorized and requested to disclose information and records pertaining to my physical health or condition, whether past, present or future, including all physicals, physicians records, athletic trainers records, diagnoses, treatment information, histories, and prognoses, and including information and records pertaining to any and all injuries or illnesses to (i) Northeastern University Department of Athletics and its personnel (including coaches of my sport) who the University, in good faith, determines have a legitimate need to know and/or (ii) Northeastern University s team physicians; but only disclosing such information to the media as it relates to my ability to participate in my sport. The purpose of this authorization is (i) to assist coaches and other personnel within the Department of Athletics in evaluating my fitness as it pertains to my ability to participate in my sport; (ii) to allow personnel within the Department of Athletics to assist me with respect to my athletic grant-in-aid or with respect to my academic progress; (iii) to assist Northeastern University s team physicians in providing medical care to me; (iv) to meet the requirements of insurers or health plans when such insurers require such information before paying for your health care services; and/or (v) to allow athletic training students and student physicians in training to participate in my medical care or to contribute to their educational training. I hereby agree that the information that is used or disclosed pursuant to this Authorization may be re-disclosed by the receiving entity. For example, information given to the media about my physical ability to play my sport will, in all likelihood, be re-disclosed to their audience. By signing below, I specifically authorize and consent to all such re-disclosures. I understand that the information referenced above is protected by law and may not be disclosed without my consent. By signing this form, I certify that I agree to the disclosure of the records referenced above. A copy of this authorization shall be considered as effective and valid as the original. Student-Athlete Signature Signature of Parent/Guardian if Student-Athlete is Under 18 Years of Age DATE: DATE:

Northeastern University Athletic Medical Insurance Coverage Despite our best preventative efforts athletic injuries will occur, many of which will require specialty medical services outside of the Sports Medicine department and the University Health and Counseling Services (student health service). It is very important that you fully understand the Northeastern University policy regarding medical insurance coverage for athletic injuries. Northeastern University does not provide primary medical insurance coverage for intercollegiate athletes or any other special activities group. All medical expenses incurred (including deductibles, co-payments, and other charges) for treatment of athletic related injuries are the responsibility of the student-athlete. This includes, but is not limited to; expenses related to MRI s, bone scans, lab tests, x-rays, hospitalization, surgery, emergency room services, emergency transportation, dental, physical therapy, chiropractic care or other alternative treatments, lost corrective lenses, or medications to treat injuries, illnesses or other medical conditions. This policy applies regardless of whether or not the injury was sustained in a formal practice or competition while representing Northeastern University, either on our campus or while visiting another institution. Northeastern University Athletics will, however, provide insurance for all of our student-athletes that will cover those expenses (other than deductibles) not covered by your primary insurance for any injury incurred during athletic practice or competition. All Northeastern University students are required to provide proof of medical insurance upon entrance to Northeastern. Full-time students at Northeastern University must either enroll in the Northeastern University Student Health Plan or have an approved waiver for coverage under an existing family medical insurance policy. In compliance with Massachusetts State Law all full-time and part-time students meeting 9 quarter/semester credit hours or more will automatically be enrolled in the Northeastern University Student Health Plan. If you have comparable insurance coverage you may waive the Northeastern University Student Health Plan on line at www.myneu.neu.edu. If you do not take the appropriate steps to waive the Northeastern University Student Health Plan, you will automatically be enrolled and therefore you will incur the cost of this plan. Be aware that when purchasing the Northeastern University Student Health Plan, deductibles and co-payments are still in effect. Northeastern Athletic and Sports Medicine Departments strongly urge all student-athletes and their families to closely examine the access to care and benefits associated with an on-campus healthcare plan compared to personal insurance plans, especially for out-of-state athletes. For more information regarding the Northeastern University Student Health Plan, please call The Blue Cross Blue Shield of MA Group directly at 1-888-648-0825 or call University Health and Counseling Services at 1-617-373-2772. As always, if you have any questions, please ask a the Risk Services office or a member of the Sports Medicine staff. Please be advised that this information is our best current understanding of the process, and may change without notice. ---------------------------------------------------------------------------------------------------------------------------------------------------------- I have read and understand the above insurance procedure for student-athletes. This form must be signed and returned prior to clearance for athletic participation for your son/daughter. Student-Athlete Signature: DATE Parent/Guardian Signature (if Student-Athlete is a minor): DATE

NORTHEASTERN UNIVERSITY MEDICAL HISTORY & PRE-PARTICIPATION PHYSICAL EXAMINATION FORM Examiner, This athlete should provide you with a completed Northeastern University Medical History from SportsWare with this examination form. Please review that history as part of your physical examination. I certify that I have reviewed the Northeastern University Medical History form previously completed by the patient prior to and in conjunction with the following Pre-participation Physical Examination. Name of practitioner (please print) Practitioner's Signature: Date: Northeastern University Use ONLY Below this Line Reviewed by Northeastern University Sports Medicine staff (ATC, MD, PA)

Northeastern University Pre-Participation Physical Examination Form Physician Student-Athlete s Name_ Date of Exam / / Date of Birth / / Sports MUSCULOSKELETAL ***(Record any ROM Limitations, Deformities, Abnormalities)*** Normal Findings NECK SHOULDER (R ) (L) ELBOW WRIST (R) (R) (L) (L) HANDS/FINGERS (R) (L) SPINE/THORAX HIP/THIGH (R) (L) KNEE (R) (L) ANKLE (R) (L) LOWER LEG FEET/TOES (R) (R) (L) (L) VISUAL ACUITY: L) R) Corrected: NO Pupils: Equal Unequal DOMINANCE: EYE_ HAND

HEARING: Optional or if indicated 500 1000 2000 4000 500 1000 2000 4000 Left Right (Left ear ) (Right ear ) URINALYSIS: Optional Glucose Bilirubin Ketone SG Blood Ph Protein Urobilinogen Nitrate Leukocytes GENERAL MEDICAL: HEIGHT: WEIGHT: BLOOD PRESSURE: /_ PULSE: NORMAL ABNORMAL NORMAL ABNORMAL HEAD RESPIRATORY EYES EAR, NOSE, THROAT NECK SKIN LYMPH NODES HEART ABDOMEN URINARY GENITALIA OTHER OTHER PULSES According to American Heart Association Guidelines, the cardiovascular physical examination should emphasize (but not necessarily be limited to): 1) Precordial auscultation in both supine and standing positions to identify, in particular, heart murmurs consistent with dynamic left ventricular outflow obstruction 2) Assessment of femoral artery pulses to exclude coarctation of the aorta 3) Recognition of the physical stigmata of Marfan Syndrome 4) Brachial blood pressure measurement in the sitting position When cardiovascular abnormalities are identified or suspected, the athlete should be referred to a cardiovascular specialist for further evaluation Practitioner s Comments/Recommendations:_ DENTAL:

OVERALL PHYSICAL EXAMINATION RESULTS: I hereby certify that each examination listed above was performed by me or an individual under my direct supervision with the following conclusion(s): RESULTS PASSED WITHOUT LIMITATIONS No clear contraindication to sports participation PASSED PENDING THE FOLLOWING: FAILED DUE TO THE FOLLOWING: CHECK ONE COMMENTS At this date, I can find no physical abnormality that would deter this student from fully participating in all of the sports listed below, except the ones that are circled: Baseball, Basketball, Cross Country, Field Hockey, Football, Ice Hockey, Rowing, Soccer, Swimming/Diving, Track & Field, Volleyball, Weight Training Name of practitioner (please print or stamp) Address Practitioner's Signature: Date: