SPORT MANHATTAN COLLEGE Department of Athletics Health-Status Questionnaire

Transcription

1 SPORT MANHATTAN COLLEGE Department of Athletics Health-Status Questionnaire NOTE: to all incoming freshman and transfer students... this form is NOT a medical record. A separate medical record must be completed and sent to health services in order to be medically cleared for school AND athletics. This form must be returned to athletics. Participation in sports requires an acceptance of risk of injury. Athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precautions to minimize the risk of significant injury and that those participating in the sport will not intentionally inflict injury. Periodic analysis of injury patterns continuously lead to refinements in the rules and other safety guidelines. However to legislate safety via the rule book and equipment standards, although often necessary, is seldom effective by itself. To rely on officials to enforce compliance with the rule book is as insufficient as to rely on warning labels to produce behavioral compliance with safety guidelines. Compliance means respect on everyone s part for the intent and purpose of a rule or guideline, not merely technical satisfaction by some of its phrasing. This annual form must be completed and returned before an athlete will be permitted to practice or play. STUDENT S FULL NAME Please Print (Last) (First) (Initial) CIRCLE ONE: FRESHMAN SOPHOMORE JUNIOR SENIOR TRANSFER if a transfer, please circle class designation also The National Collegiate Athletic Association s (N.C.A.A.) policies recommend that all student-athletes have qualifying medical evaluations upon their initial entrance into an institution s intercollegiate athletics program. Manhattan College supports and adheres to this N.C.A.A. policy. Further medical evaluations (subsequent to the initial qualifying exam) may be required in specific cases. DATE OF COLLEGE ADMISSION PHYSICAL EXAMINATION DATE OF THE LAST TIME YOU COMPLETED THIS FORM THE FOLLOWING QUESTIONS MUST HAVE CURRENT ANSWERS BY THE STUDENT-ATHLETE 1. Have you been hospitalized for any reason since the above exam? If yes, give DATE and REASON YES NO 2. Are you currently ill in any way? If yes, describe NATURE of illness YES NO 3. Have you had any injury, including cerebral concussion, since the above exam? If yes, please give DATE and NATURE of injury. YES NO 4. Do you currently have any incompletely healed injury? If yes, explain. YES NO 5. Are you currently taking any medication or taking medication on a regular or continuing basis? If yes, give NAME of medications an WHY you are taking the medication. YES NO 6. Are you allergic to any medication/bee stings, etc.? If yes, give name of medication YES NO 7. Since your last medical exam, have you passed out during exercise or stopped because of dizziness? YES NO 8. Do you know of, or do you believe there is, any health reason why you should not participate in the College's intercollegiate program at this time? If yes, explain. YES NO The undersigned, herewith, A. Understands that he/she must refrain from practice or play while ill or injured, whether or not receiving medical treatment, and during medical treatment until he/she is discharged from treatment or is given permission by the clinical practitioner to restart participation despite continuing treatment. B. Understands that having passed the physical examination does not necessarily mean that he/she is physically qualified to engage in athletics but only that the examiner did not find a medical reason to disqualify him/her at the time of said exam. *C. Accepts responsibility for reporting injuries and illness to the college athletic training staff, including signs and symptoms of concussions. D. Certifies that the answers to the questions above are correct and true. *Please note this statement is new to this document as of PERSONAL LOCAL CELL PHONE # NAME OF EMERGENCY CONTACT TELEPHONE # STUDENT-ATHLETE SIGNATURE DATE SIGNATURE OF PARENT OR LEGAL GUARDIAN (IF UNDER THE AGE OF 18) DATE

2 Pre-participation Physical Evaluation: HISTORY FORM Name Date of Birth Year of Graduation SS# Home Address Emergency Contact Name Relationship Phone(C) Phone(W) Consent for Emergency Medical Treatment I herby give authority to Manhattan College to obtain the necessary emergency medical treatment for me with the understanding that the above mentioned person will be notified as soon as possible. Signature Signature of Parent/Guardian (under 18) Date GENERAL QUESTIONS YES NO 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Are you currently taking any prescription or nonprescription (over-thecounter) medicines or pills? 3. Do you have any allergies to medicines, pollens, food or stinging insects? 4. Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes Infections Other: 5. Have you ever spent the night in the hospital? 6. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU YES NO 7. Have you ever passed out DURING or AFTER exercise? 8. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 9. Does your heart ever race or skip beats (irregular beats) during exercise? 10. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High blood pressure High cholesterol Kawasaki disease A heart murmur A heart infection Other: 11. Has a doctor ever ordered a test for your heart? (for example, ECG/EKG, electrocardiogram) 12. Do you get lightheaded or feel more short of breath than expected during exercise? 13. Have you ever had an unexplained seizure? 14. Do you get more tired or short of breath more quickly than your friends during exercise? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY YES NO 15. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before the age of 50 (including drowning, unexplained car accident, or sudden infant death syndrome)? 16. Does anyone in your family have hypertrophic cardiomyopathy, marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic plymorphic ventricular tachycardia? 17. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 18. Has anyone in your family had an unexplained fainting, unexplained seizures, or near drowning? BONE AND JOINT QUESTIONS YES NO 19. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss practice or a game? 20. Have you ever had any broken or fractured bones or dislocations? 21. have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? exercise? 29. Have you ever used an inhaler or taken asthma medicine? 30. Is there anyone in your family who has asthma? 31. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? 32. Do you have groin pain or a painful bulge or hernia in the groin area? 33. Have you had infectious mononucleosis (mono) within the last month? 34. Do you have any rashes, pressure sores, or other skin problems? 35. Have you had herpes or MRSA skin infection? 36. Have you ever had a head injury or skin infection? 37. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? 38. Do you have a history of seizure disorder? 39. Do you have headaches with exercise? 40. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? 41. Have you ever been unable to move your arms or legs after being hit or falling? 42. Have you ever become ill while exercising in the heat? 43. Do you get frequent muscle cramps when exercising? 44. Do you or someone in your family have sickle cell trait or disease? 45. Have you had any problems with your eyes or vision? 46. Have you had any eye injuries? 47. Do you wear glasses or contact lenses? 48. Do you wear protective eyewear, such as goggles or a face shield? 49. Do you worry about your weight? 50. Are you trying to or has anyone recommended that you gain or lose weight? 51. Are you on a special diet or do you avoid certain types of foods? 52. Have you ever been treated for an eating disorder, depression, anxiety or other mental health issue? 53. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY YES NO 54. Have you ever had a menstrual period? 55. How old were you when you had your first menstrual period/ 56. How many periods have you had in the last 12 months? Explain yes answers here: 22. Have you ever had a stress fracture? 23. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (down syndrome or dwarfism) 24. Do you regularly use a brace, orthotics, or other assistive device? 25. Do you have a bone, muscle, or joint injury that bothers you? 26. Do any of your joints become painful, swollen, feel warm, or look red? 27. Do you have a history of juvenile arthritis or connective tissue disease? MEDICAL QUESTIONS YES NO 28. Do you cough, wheeze, or have difficulty breathing during or after I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Signature of parent/guardian (under 18) Date

3 Pre-participation Physical Evaluation: Examination Height: Weight: Blood Pressure: / Pulse: Male Female Medical (Official use) Normal Abnormal Findings 1. Heart Murmur- exam supine and standing or with Valsalva, specifically to identify murmurs of dynamic Left ventricular outflow tract obstruction 2. Femoral pulse to exclude aortic stenosis 3. Physical stigmata of Marfan Syndrome Orthopedic Screen (Official use) Normal Abnormal Findings Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional: Duck walk, SL hop Pre-participation Physical Evaluation: Clearance (Official use only) Cleared for Competition: YES NO Cleared after completing further evaluation/rehabilitation for: Not cleared due to: Recommendations: Signature Print Name Date:

4 Sickle Cell Testing Waiver The Manhattan College Sports Medicine Department has prepared this statement and waiver on testing of Sickle Cell Trait for the education, protection and welfare of the student-athlete. Definition of Sickle Cell Trait: Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. During intense exercise, red blood cells containing the sickle hemoglobin can change from round to quarter-moon, or sickle. Sickled red blood cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to tissues and muscle. During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died. Heat, dehydration, altitude and asthma can increase the risk for complications associated with sickle cell trait, even when exercise is not intense. People at High Risk for Sickle cell Trait: People at high risk for having sickle cell trait are those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries. Eight percent of the U.S. African American population has the sickle cell trait. How can I prevent a collapse: Engage in a slow and gradual preseason conditioning regimen. Build up your intensity slowly while training. Use adequate rest and recovery between repetitions. Avoid pushing with all-out exertion longer than two to three minutes without a rest interval or a breather. Stay well hydrated at all times, especially in hot and humid conditions. Maintain proper asthma management. Be aware when adjusting to a change in altitude. Avoid using high caffeine energy drinks or supplements. If you experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness, stop activity immediately and notify your athletic trainer and/or coach. I understand that NCAA rules require that all Division I athletes be tested for the Sickle Cell Trait, unless I refuse such testing. I have been fully informed of any and all risks that I may incur while participating in intercollegiate athletics at Manhattan College with the absence of testing for the sickle cell trait. It is my express intent that this waiver shall bind my family, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue Manhattan College, its trustees, officers, agents, and employees. I hereby further agree that this sickle cell trait testing waiver shall be construed in accordance with the laws of the State of New York. In signing this release, I acknowledge and represent that I have read the foregoing, Sickle Cell Trait Testing Waiver Release understand it and sign it voluntarily; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by the same. Parent/Guardian s signature required for individuals under eighteen (18) years of age. Signature of Student-Athlete Date Signature of Parent/Gaurdian Date

5 Manhattan College Sports Medicine Insurance Information US federal law, per the Affordable health Care Act, requires all US citizens to have health insurance coverage. All Manhattan College athletes, regardless of US citizenship status, must be covered by their own personal health insurance. No athlete may participate in Manhattan College Athletics without providing proof of their own personal health insurance. Athletes that cannot obtain health insurance may request a waiver to this rule. In order to request a waiver an athlete must meet with their respective Head Coach as well as the Head Athletic Trainer and the Director of Intercollegiate Athletics. The athletic department carries a secondary insurance policy to cover an athlete s injuries sustained while participating in Manhattan College athletics. This is an excess policy, which pays for only what is not covered by the student athlete s private insurance. Each athlete is required to have their own insurance, and have their insurance information on file with the sports medicine department. All insurance claims must be billed to the athlete s primary insurance first, followed by the Manhattan College Policy secondarily. Please complete the following information about your Private Primary Health Insurance Company, and provide a copy of the front and back of your insurance card. Primary Insurance Co. Insurance address Insurance phone# Insurance fax# Policy # Group #(if applicable) Name of parent or guardian you are insured through Insured parents date of birth / / Home address of insured Parent/gaurdain phone#: home/cell work Parent/guardian employer Do you have a Secondary Insurance Company? YES NO If yes, please complete the following information about your other health insurance company. Secondary Insurance Company Insurance address Insurance phone# Insurance fax# Policy # Group #(if applicable) Name of parent or guardian you are insured through Insured parent/guardians date of birth / / Home address of insured Parent/guardian phone#: home/cell work Parent/guardian employer Does your insurance require a referral from your primary care physician? YES NO Does your insurance require pre-authorization before any medical tests or treatment is preformed? YES NO I authorize the Manhattan College Sports Medicine Department to share information necessary for treatment with Manhattan team physicians, student health services, coaches, administrators, and parent(s) / guardian(s). I have been informed that I have the right to revoke this authorization at any time. I understand that my medical records are kept secure and that I have the right to view those records upon request. Parent s signature (under 18 only) Student s signature Date Date

6 MANHATTAN COLLEGE SPORTS MEDICINE DEPARTMENT OF INTERCOLLEGIATE ATHLETICS Authorization for the Release of Medical Information to Sports Medicine Staff, Coaches, Athletic Staff, Student Staff, Parents, Teammates, Media, and Professional Sports Teams Student-Athlete: Sport: This authorizes the athletic trainers, team physicians and sports medicine staff representing Manhattan College to release information concerning my medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information to all of the following relevant to past, present or future participation in athletics at Manhattan College. Please initial the appropriate parties: Initial Sports Medicine Staff, including Team Physicians and Athletic Trainers Initial Health Services Nurses and Physicians Initial Coaches and Assistant Coaches Initial Other Athletics Staff Initial Student Members of the Sports Medicine Staff Initial Parents or Legal Guardians Initial Teammates Initial Media Initial Professional Teams and Representatives The reason for this disclosure is to advise these individuals to the nature, diagnosis, prognosis or treatment concerning my medical condition and any injuries or illnesses so that they may make decisions regarding my athletic ability and suitability to compete while I am a student athlete. I understand that the individuals that receive the information are not health care providers covered by federal privacy regulations, and that the information described above may be redisclosed publicly and that the information will no longer be protected by those regulations. I understand that Manhattan College will not receive compensation for its use/disclosure of the information. I understand that if I may refuse to check a particular box indicating that I do not want my medical information released to those particular individuals and that my refusal to check a box will not affect my ability to obtain treatment. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I may inspect or copy any information used/disclosed under this authorization. I understand that I may revoke this authorization in writing at any time by notifying in writing the Director of Division of Sports Medicine, but if I do, it will not have any effect on the actions Manhattan College took in reliance on this authorization prior to receiving the revocation. This consent is valid for all care provided for at least one (1) year from the date I signed this agreement. Signature of Student-Athlete Signature of Parent/Legal Guardian (If student athlete is under 18 years of age) Date of Signature Date of Signature