Edward Waters College Athletic Training General Information Form

Transcription

1 Edward Waters College Athletic Training General Information Form Mobile Phone: ( ) Classification: Student-Athlete Name (Last, First, Middle): Sport: of Birth: / / Social Security Number: Permanent Address Street: City, State, Zip: Emergency Contact Name: Relationship: Street: City, State, Zip: Phone: ( )

2 Edward Waters College Athletic Training Medical Insurance Information/Authorization Dear Parents or Guardian(s): Primary Care Insurance is required here at Edward Waters College to participate in any athletics. Insurance is solely provided by the parent and/or athlete. Failure to do so will result in disqualification in any athletics here at Edward Waters College. Please provide the information requested below, i.e., Medical Insurance information/authorization, claim forms, copy of insurance card, copy of prescription card, etc. Is your student-athlete covered by Medical Insurance? YES NO If YES, does your Insurance company require pre-certification for surgeries/service? YES NO DOWNLOAD THE NExTT PIC APP TO UPLOAD YOUR INSURANCE CARD IMAGE; FOLLOW INSTRUCTIONS Enter School Name, Student Name, and Student ID or DOB on the first screen. It will then show two boxes to capture the front and back of card. Position your device to fit the card image in the border and the camera will auto-focus to take picture. Click Submit when done. INSURANCE COMPANY #1: POLICY# GROUP# DEDUCTIBLE $ MAILING ADDRESS FOR INSURANCE COMPANY CLAIMS OFFICE PHONE INSURANCE COMPANY #2: POLICY# GROUP# DEDUCTIBLE $ MAILING ADDRESS FOR INSURANCE COMPANY CLAIMS OFFICE PHONE I HAVE READ THE ABOVE AND FOREGOING MEDICAL INSURANCE INFORMATION AND UNDERSTAND THE STATES CONTAINRED THEREIN Signature of Parent/Guardian or Athlete

3 Edward Waters College Athletic Training Medical History The following information is kept confidential and will not be released to any individual without your authorization. Family History: Has any blood relative ever had any of the following? Cancer YES NO Tuberculosis YES NO Diabetes YES NO High Blood Pressure YES NO Stroke YES NO Epilepsy YES NO Sickle Cell Disease or Trait YES NO Heart Conditions including: Arrhythmias, hypertrophic cardiomyopathy, long QT YES NO Died of heart problems or sudden death under the age of 50? YES NO Allergies List Allergies to Medications, Foods, Others: Are you allergic to: Bee Stings YES NO Adhesive Tape YES NO Do you use or have an EpiPen? YES NO

4 Edward Waters College Athletic Training Personal Medical History Please check any of the following conditions or illness that you have suffered from or told that you may be at risk for, and supply approximate date: Infectious Mononucleosis Sickle Cell Disease or Trait Rheumatic Fever Chicken Pox Mumps Cancer (Type) Diabetes Sexually Transmitted Disease Skin Problems Frequent/severe headaches Epilepsy/Convulsions/Seizures Stomach trouble/ulcer Gall bladder problems Rectal Bleeding/Hemorrhoids Liver Problems Bladder/Urinary tract problems Excessive Leg Cramping High/Low Blood Pressure Loss of Consciousness/knocked out Chest pain, fainting, or near fainting with exercise Palpitations/Irregular heart beat Pneumonia Tuberculosis ADHD or ADD Depression/Anxiety Eating Disorder Meningitis Birth Defects Cold Sores Gout Concussion Dizziness Hepatitis Frequent Diarrhea Constipation Kidney Problems Arthritis/Rheumatism Anemia Excessive or unexplained shortness of breath/wheezing with exercise Heat Exhaustion/Heat Stroke/Trouble exercising in the heat Heart Murmur

5 Edward Waters College Athletic Training Orthopedic History Please check and date any of the following body parts that you have suffered any injury: Head/Neck Back Chest Shoulder Arm Elbow Wrist Hands/Fingers Hips/Thighs Ankles/Feet Lower Legs Knees Please provide date and type of injury, right or left (if applicable), and surgeries required and special tests: Medications Are you currently taking any medications? YES NO If yes, please list: Surgeries Have you had surgery? YES NO If yes, please specify: Medical Hospitalization Have you been hospitalized overnight? YES NO If yes, list reason(s): Eyes Do you wear glasses? YES NO Do you wear contact lenses? YES NO Have you ever had a serious eye injury? YES NO If yes, please explain: Mental Health Have you ever been treated for drug or alcohol problems? YES NO Have you ever been treated for an emotional disorder? YES NO Have you ever experienced periods of depression? YES NO What medication(s) have you taken or currently take for emotional problems?

6 Substance Use Do you regularly use tobacco products (cigarettes, chewing tobacco, etc.) YES NO Do you drink alcohol? YES NO If yes for tobacco or alcohol, please specify use: Female Health History of last gynecological exam / / Are your periods regular? YES NO Start date of last period / / Interval (number of days) between periods: Have you ever gone more than two months without a period? YES NO If yes, when? How many months missed? Have you ever been pregnant? YES NO Do menstrual cramps interfere with your activities? YES NO Are you currently taking oral contraceptives? YES NO ALL STUDENT-ATHLETES MUST SIGN BELOW I do hereby state that, to the best of my knowledge, the medical history that I have provided is complete, correct, and accurate. Failure to report any pre-existing injury or condition may result in full liability for cost related to treatment. Student Athlete Signature Parent Signature* (*If Athlete is under 18 years old)

7 EXAMINATION Male Female Height: Weight: BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected Y N MEDICAL NORMAL ABNORMAL FINDINGS Appearance HEENT Lymph Nodes Heart Pulses Lungs Abdomen Genitourinary (males only) Skin Neurological MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional Duck-walk, single leg hop Cleared for all sports without restriction Cleared for all sports without restriction with some recommendations for further evaluation or treatment Not cleared Pending further evaluation For any sports For certain sports Reason: Recommendations: I have examined the above-named student and completed the pre-participation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician nay rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians). Name of Physician Address/Hospital Signature Phone MD/DO

8 Edward Waters College Athletic Participation Assumption of Risk The undersigned herewith formally acknowledges and declares the following shared responsibility statement: I understand that participation in sport-based training requires a personal acceptance of risk of injury. Athletes generally expect that those who are responsible for the conduct of sport take reasonable precautions to minimize such risk and that their peers participating in the sport will not intentionally inflict wrongful injury upon them I understand that the athletic participation at Edward Waters College may result in injury, illness, permanent physical or mental impairment, or even death. These injuries may be minor or ma be career or life threatening. I understand that Edward Waters College cannot be held responsible for any injuries or conditions that may be caused by the actions of other students or teams. I also understand that injuries may be caused by my own failure to follow safety procedures or techniques which are made known to me by my coaching staff, athletic training staff or by strength and conditioning personnel, or are otherwise known to me from another source, including but not limited to medical personnel of the College I have read the above shared responsibility statement. I understand that there are certain inherent risks involved in participating in athletic-based training. I acknowledge the fact that these risks exist and I am willing to assume responsibility for any and all such risks while participating in athletic-based training at Edward Waters College. I also agree to the following: 1. I voluntarily assume all risks associated with my participation in voluntary athletic-based training 2. I accept that Edward Waters College and its personnel are not to be held responsible for any pre-existing medical condition(s) that I may have 3. I understand that passing the pre-participation physical exam does not necessarily mean that I am physically qualified to participate in athletic-based training at Edward Waters College, but only that the evaluator did not find a medical reason to disqualify me at the time of the pre-participation physical exam. 4. I understand that I must refrain from practices and competition while injured or ill, whether or not receiving medical care. When under medical care I may not return to participation until I have been given permission, based on an independent exercise of professional judgment, by the Certified Athletic Trainers, Team Physician(s), or his/her designated family appointed medical representative. 5. I understand and agree that if I experience an injury, illness or change in my health status it is my responsibility to inform the supervising coach and the Athletic Training Staff and to adhere to the established injury management guidelines, which include total rehabilitation and reassessments before I am released to return to full participation. 6. I understand that I must wear the proper equipment as dictated by the rules of the supervising coach. I may also have to wear padding or braces as indicated by the Athletic Training Staff or Medical Personnel. Failure to do so may put me at risk for further injury. I HAVE READ AND UNDERSTAND, AND VOLUNTARILIY AGREE TO THE ABOVE STATEMENTS. Print Name Participant Signature Athletic Training Staff Signature Birth date

9 HIPAA RELEASE FORM I understand that my injury/illness information is protected by federal regulation under with the Health Information Portability and Accountability Act (HIPAA) of Family Education 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 my signing of this authorization/consent is voluntary and that my institution will not condition any benefits on whether I provide the consent or authorization requested for this disclosure. I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete for Edward Waters College. I, am allowing FULL disclosure of my personal health information. This includes diagnostic results, treatments, surgeries, and information regarding any athletic injury or illness I may sustain while participating in intercollegiate athletics at Edward Waters College. Such information will be used with the best interest of the patient s health in mind. All of the following individuals may be told about my condition(s): Edward Waters College Athletic Trainers The coaching staff for the sports I participate in My parents/family: (Please print name, address & telephone number of the parent(s)/guardian(s) to whom the information may be released. Edward Waters College Athletic Directors/Administrators Edward Waters College Team Physicians, and their Office Staff Any Treating Doctor/Physical Therapist or Medical Care Provider for an injury/illness I sustained while competing at Edward Waters College. Medical Insurance Coordinators, Insurance Carriers I understand that I may revoke this authorization/consent at any time by notifying in writing the Head Athletic Trainer, but if I do, it will not have any effect on actions Edward Waters College has taken in reliance on this authorization/consent prior to receiving the revocation. I understand that I may receive a copy of this authorization. This authorization/consent expired six (6) years from the date it is signed. Print Name of the Student Signature of the Student

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11 STUDENT CONCUSSION AGREEMENT FORM I, agree that I have read the previous fact sheet on concussions and understand the risks of not reporting any symptoms listed on the sheet. I understand that to properly diagnose a concussion, that I must report any signs and symptoms immediately to a member of the Edward Waters College Athletic Training Staff, who will then perform a full assessment of my injury and determine the proper course of action. Student Athlete Signature Parent Signature*