NAME: SEX: AGE: DATE OF BIRTH: CLASSIFICATION SPORT(S): HOME ADDRESS: PRIMARY PHONE:

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1 BETHEL UIVERSITY PREPARTICIPATIO EVALUATIO DATE OF EXAM: HISTORY FORM AME: SEX: AGE: DATE OF BIRTH: CLASSIFICATIO SPORT(S): HOME ADDRESS: PRIMARY PHOE: PERSOAL PHYSICIA: PROVIDER PHOE UMBER STATE/ COUTRY EXPLAI YES ASWERS BELOW. CIRCLE QUESTIOS YOU DO T KOW THE ASWERS TO. The Exam portion of this form must be completed by a licensed MD, DO, FP, or PA-C within the United States of America. 1. Has a doctor ever denied or restricted your participation in sports for any reason?... Y 2. Do you have an ongoing medical condition (like diabetes or asthma)?... Y 3. Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills?... Y 4. Do you have allergies to medicines, pollens, foods, or stinging insects?... Y 5. Have you ever passed out or nearly passed out DURIG exercise?... Y 6. Have you ever passed out or nearly passed out AFTER exercise?... Y 7. Have you ever had discomfort, pain, or pressure in your chest during exercise?... Y 8. Does your heart race or skip beats during exercise?... Y 9. Has a doctor ever told you that you have: High Blood Pressure... Y High Cholesterol... Y A heart murmur... Y A Long QT..Y A heart infection... Y 10. Has a doctor ever ordered a test for your heart? (for example, ECG, echocardiogram)... Y 11. Has anyone in your family died for no apparent reason?... Y 12. Does anyone in your family have a heart problem?... Y 13. Has any family member or relative died of heart problems or of sudden death before age 50?... Y 14. Does anyone in your family have Marfan Syndrome?... Y 15. Have you ever spent the night in a hospital?... Y 16. Have you ever had surgery?... Y 17. Have you ever had an injury, like a sprain, muscle or ligament tear, or tendonitis, that caused you to miss a practice or game?... Y If Yes, explain: 18. Have you had any broken or fractured bones or dislocated joints?... Y If Yes, explain: 19. Have you ever had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches?... Y If Yes, explain: 20. Have you ever had a stress fracture?... Y 21. Have you been told that you have or have had an x-ray for atlantoaxial (neck) instability?... Y 22. Do you regularly use a brace or assistive device?... Y 23. Has a doctor ever told you that you have asthma or allergies?... Y 24. Do you cough, wheeze, or have difficulty breathing during or after exercise?... Y 25. Is there anyone in your family who has asthma?... Y 26. Have you ever used an inhaler or taken asthma medicine?... Y 27. Were you born without or are you missing a kidney, an eye, a testicle, or any other organ?... Y 28. Have you had infectious mononucleosis (mono) within the last month?... Y 29. Do you have rashes, pressure sores, or other skin problems?... Y 30. Have you ever had a herpes skin infection?... Y 31. Have you ever had a head injury or concussion?... Y 32. Have you been hit in the head and been confused or lost your memory?... Y 33. Have you ever had a seizure?... Y 34. Do you have headaches with exercise?... Y 35. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?... Y 36. Have you ever been unable to move your arms or legs after being hit or falling?... Y 37. When exercising in the heat, do you have severe muscle cramps or become ill?... Y 38. Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?... Y 39. Have you had any problems with your eyes or vision?... Y 40. Do you wear glasses or contact lenses?... Y 41. Do you wear protective eyewear, such as goggles or a face shield?... Y 42. Are you happy with your weight?... Y 43. Are you trying to gain or lose weight?... Y 44. Has anyone recommended you change your weight or eating habits?... Y 45. Do you limit or carefully control what you eat?... Y 46. Do you have any concerns that you would like to discuss with a doctor?... Y FEMALES OLY 47. Have you ever had a menstrual period?... Y 48. How old were you when you had your first menstrual period? 49. How many periods have you had in the last 12 Months? Explain Yes answers on next page.

2 BETHEL UIVERSITY PREPARTICIPATIO EVALUATIO AME: DATE OF BIRTH: SCHOOL: HEIGHT: WEIGHT: % BODY FAT (OPT.): PULSE: BP: / ( /, / ) VISIO R 20/ L 20/ CORRECTED: Y PUPILS: EQUAL UEQUAL HISTORY FORM Follow-Up Questions on More Sensitive Issues 1. Do you feel stressed out or under a lot of pressure?... Y 2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days?... Y 3. Do you feel safe?... Y 4. Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke?... Y 5. During the past 30 days, did you use chewing tobacco, snuff, or dip?... Y 6. During the past 30 days, have you had at least 1 drink of alcohol?... Y 7. Have you ever taken steroid pills or shots without a doctor s prescription?... Y 8. Have you ever taken any supplements to help you gain or lose weight or improve your performance?... Y 9. Questions from the Youth Risk Behavior Survey ( on guns, seatbelts, unprotected sex, domestic violence, drugs, etc.... Y Explain any Yes answers here from History: Providers otes: I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Athlete s Signature: : Parent/Guardian Signature if under 18 yrs of age: :

3 BETHEL UIVERSITY PREPARTICIPATIO EVALUATIO MEDICAL EXAMIATIO FORM AME: SEX: AGE: DATE OF BIRTH: SCHOOL: Classification: MEDICAL Appearance Eyes/ears/nose/throat Hearing Lymph nodes Heart Murmurs Pulses Lungs Abdomen Genitourinary (males only)** Skin MUSCULOSKELETAL eck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/Toes ORMAL ABORMAL FIDIGS IITIALS* *Multiple-examiner set-up only. **Having a third party present is recommended for the genitourinary examination. otes: Questions taken from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedeic Society for Sports Medicine, & American Ortheopathic Academy of Sports Medicine 2004 PPE Form

4 BETHEL UIVERSITY PREPARTICIPATIO EVALUATIO CLEARACE FORM AME: SEX: AGE: DATE OF BIRTH: SCHOOL: Classification: Cleared without restriction no EKG is needed based upon exam Cleared, with recommendations for further evaluation or treatment for: ot cleared until EKG/ECG or further cardiac testing is competed. Please Site Reason and Recommendations. ot cleared for All sports Certain Sports: Reason: Recommendations: EMERGECY IFORMATIO Parent/Guardian Phone Alternate Contact Allergies: Other Information: IMMUIZATIOS (eg, tetanus/diphtheria; measles, mumps, rubella; hepatitis A, B; influenza; pneumococcal; meningococcal; varicella) Up to date (see attached documentation) ame of physician (print/type): Address: Signature of physician: ot up to date Specify : Phone: MD or DO Signature of Midlevel: P or PA-C State License umber (Required) Adapted from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedeic Society for Sports Medicine, & American Ortheopathic Academy of Sports Medicine 2004 PPE Form.

5 Bethel Department of Athletics Medical Authorization Forms ame (please print): I hereby authorize the physicians, athletic trainers, sports medicine staff, and other health care personnel representing Bethel University to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics. This protected health information may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic participation status, and related personally identifiable health information. This protected health information may be released to other health care providers, parents/guardians, hospitals and/or medical clinics and laboratories, athletic coaches, strength and conditioning coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or service companies, academic counselors, athletic and/or university administrators, chaplains and/or clergy members, and members of the media. I also agree and understand that my protected health information (PHI) will be used to educate students in the Athletic Training Education Program at Bethel University. I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete for Bethel University. I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment. I understand that I may revoke this authorization/consent at any time by notifying in writing the Athletic Training Staff at Bethel University, but if I do, it will not have any effect on actions Bethel University took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires six (6) years from the date it is signed. Authorization to Release Information I authorize the Bethel University Sports Medicine Department, attending physician, and/or designated certified athletic trainer to release any personal medical information to the coaching staff, Bethel administrative staff, athletic training students, insurance companies, professional athletic teams, other attending physicians, and the hospitals or other medical facilities. Signed Authorization for Medical Information I hereby authorize all physicians, hospitals, and other medical personnel to furnish full and complete medical reports and information requested concerning injuries and illnesses received that would pertain to participation in collegiate athletics to Bethel Sports Medicine. This authorization also includes examination of all hospital records, x-ray films, and the furnishing of information concerning medical opinions. Signed Authorization for Reporting Injuries I have read and fully understand that if I do not report an injury within forty-five (45) days after completion of a particular athletic season, then I accept full financial responsibility of that complaint or injury. Signed

6 ame (please print): Permission to Treatment Statement I, grant permission for the Bethel Sports Medicine staff /Physicians, Athletic Training Students or affiliates to provide medical treatment sustained during as a result of an athletic injury. Permission is also granted to make decision concerning the need for medical referral and rehabilitation programs for my possible injury. Signed Waiver of Financial Responsibility I acknowledge any unauthorized treatment that may not be covered by my current health insurance carrier or Bethel s secondary intercollegiate sports carrier will be my finical responsibility. If student athletes choose not to utilize Athletic Training services before seeking medical treatment all medical expenses will become the student-athletes, parents/guardians responsibility. Signed Last Four Digits of SS# umber of Student-Athlete of Birth of Student-Athlete Signature of Parent/Legal Guardian (if student-athlete is under 18 years of age)

7 COSET TO TREAT MIOR Athlete Information Last ame First ame MI Sex: [ ] Male [ ] Female Grade Age DOB / / Allergies Medications Insurance Policy umber Group umber Insurance Phone umber Emergency Contact Information Home Address (City) (Zip) Home Phone Mother s Cell Father s Cell Mother s ame Work Phone Father s ame Work Phone Another Person to Contact Phone umber Relationship Legal/Parent Consent I/We hereby give consent for (athlete s name) to represent Bethel University Athletics in athletic participation, realizing that such activity involves potential for injury. I/We acknowledge that even with the best coaching, the most advanced equipment, and strict observation of the rules, injuries are still possible. On rare occasions these injuries are severe and result in disability, paralysis, and even death. I/We further grant permission to Bethel University, its physicians, mid-level providers, athletic trainers, counselors to render aid, treatment, rehabilitation services, medical, or surgical care deemed reasonably necessary to the health and wellbeing of the student athlete named above during or resulting from participation in athletics. By the execution of this consent, the student athlete named above and his/her parent/guardian(s) do hereby consent to screening, examination, and testing of the student athlete during the course of the pre-participation examination by those performing the evaluation, and to the taking of medical history information and the recording of that history and the findings and comments pertaining to the student athlete on the forms attached hereto by those practitioners performing the examination. As parent or legal Guardian, I/We remain fully responsible for any legal responsibility which may result from any personal actions taken by the above named student athlete. Signature of Athlete Signature of Parent/Guardian

8 SICKLE CELL TRAIT TESTIG ABOUT SICKLE CELL TRAIT: Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition (> three million Americans). Although sickle cell trait is most predominantly in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse from the rapid breakdown of muscles starving of food. The CAA recommends that all student-athletes have knowledge of their sickle cell trait status before the student-athlete participates in any intercollegiate athletic event, including strength and conditioning sessions, practice, competitions, etc. Bethel University requires sickle cell trait screening in the form of a blood test for all incoming student-athletes as part of the pre-participation physical examination process. Testing is available at your family physicians office. Student athletes will not be allowed to practice until test results are in or the waiver form is signed and submitted to the Bethel University Sports Medicine Department. If you choose not to be tested please submit this waiver: SICKLE CELL TRAIT TESTIG WAIVER I understand and acknowledge that the CAA recommends and Bethel University Department of Athletics requires that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and /or knowledge of sickle cell trait status to Bethel University Sports Medicine personnel. I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless Bethel University, its officers, medical personnel and their affiliate medical staff, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my non-compliance with the recommendation of the CAA and a requirement of Bethel University. I have read this document and acknowledge that I understand its significance. I further state that I am at least 18 years of age and competent to sign this waiver, or that if I am under 18 years of age, I have the approval of my parent and guardian to sign this waiver. Signature of Student Athlete Sport Parent/Legal Guardian