MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form ATHLETE PREVIOUS MEDICAL HISTORY (To be completed by the athlete)

Transcription

1 MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form ATHLETE PREVIOUS MEDICAL HISTORY (To be completed by the athlete) Athlete Name: LAST FIRST MI Sport(s): SSN: OPTIONAL Birthdate: MONTH / DAY / YEAR Gender: Mailing Address: NUMBER STREET CITY STATE ZIP CODE I. SPECIFIC MEDICAL QUESTIONS YES NO 1. Have you been under the care of a physician, at any time, in the past THREE years? If YES, explain: YES NO 2. Have you ever had any MAJOR illnesses or injuries? If YES, explain: YES NO 3. Have you ever had any SURGERY(s) (including illness, injury, pin, plate, screw, fracture, etc )? * PLEASE ENCLOSE THE OPERATIVE REPORTS FOR ANY SURGERIES IN THE LAST 5 YEARS IF AVAILABLE Date and Injury/Illness: YES NO 4. Have you ever declined to have a surgery that a physician (in any specialty) ever recommended? If YES, explain: YES NO 5. Have you ever had any DIAGNOSTIC TEST(s) (CT Scans, MRI, X-rays, Arthrogram, etc )? * PLEASE ENCLOSE THE REPORT FOR ANY TESTS IN THE LAST 5YEARS (IMAGES NOT NEEDED) IF AVAILABLE Date(s) and Reason(s): YES NO 6. Has a physician ever advised you NOT to participate in contact sports/athletic activity? If YES, explain: 7. Have you ever had an illness or injury involving any of the following organs? Eyes Liver Ears Loss of any paired organ or born Heart... with only 1 paired organ:. Lungs Other... Kidneys... Page 1 of 9

2 II. DISEASES/ILLNESSES/CONDITIONS Have you suffered from, or been told (by a physician or your parents) you have or have had: Chickenpox... Mononucleosis Diabetes... Mumps Epilepsy... Rheumatic Heart Disease Hepatitis... Scarlett Fever... Marfan Syndrome Tuberculosis Measles Bleeding Disorder (i.e. Hemophilia). Sickle Cell Trait or Disease.. Anemia (low hematocrit or iron).. Kidney Infection. Ulcers.. Kidney/Gull Stones Allergies... Asthma Food Allergies.. Heat Related Illness. Anxiety Depression.. Other... Eating Disorder... III. MEDICATIONS Are you presently taking any of the following: Prescription Medication... Vitamins.. Over the Counter Medication.. Asthma Medication.. Supplements ADHD Medication.. Energy Drinks Other... Caffeinated Products... (Please note : Many asthma and ADHD medications are considered banned substances by the NCAA. If you require these medications, your physician will also need to fill out the Asthma or ADHD Medication Form, found on the Malone Sports Medicine website.) IV. HEART PERSONAL HISTORY YES NO *If yes, please explain on the lines provided below this section. 1. Has a doctor ever restricted you from participating in athletics temporarily or permanently due to a heart related issue? If YES, explain below. 2. Have you ever been told you that you have a heart murmur? If YES, has it resolved? Yes No 3. Have you ever had heart or vascular surgery?... If YES, MONTH/YR 4. Have you ever had excessive exertional or unexplained dyspnea (labored breathing), fatigue, or palpitations associated with exercise?... If YES, MONTH/YR 5. Have you ever been diagnosed with high blood pressure? If YES, explain below. Page 2 of 9

3 6. Have you had abnormal chest pains, discomfort, tightness, or pressure in your chest, related to physical exertion?... If YES, MONTH/YR 7. Has a physician diagnosed you with an abnormally thickened heart or Marfan Syndrome? If YES, explain below. 8. Do you currently have, or have you ever had unexplained syncope or near syncope (fainting or passing out)?... If YES, MONTH/YR 9. Have you ever had any testing done on your heart? (Ex: Stress Test, EKG, Echocardiogram, etc.) If YES, list reasons with dates and results below. *If any Cardiac/Heart Testing has been performed (as described above), please attach copies of all test results and physician reports. This will expedite your clearance for participation. FAMILY HISTORY YES NO *If yes, please explain on the lines provided below this section. 1. Has a close relative suffered premature death due to heart disease before the age of 50? If YES, explain below. 2. Has a close relative suffered disability from heart disease before the age of 50? If YES, explain below. Has a family member been diagnosed with any of the following: Hypertrophic Cardiomyopathy... Marfan Syndrome... Dilated Cardiomyopathy.. Clinically Significant Arrhythmia.. Long QT Syndrome Other Heart Condition.. Ion Channelopathies... V. DENTAL/VISION/HEARING YES NO 1. Do you wear any dental appliance (braces, plates, permanent retainer, etc...)? If YES, explain below. 2. Have you been told that you have a loss of hearing? If YES, explain below. 3. Have you ever sustained an injury (or illness) that has affected your hearing? If YES, explain below. 4. Have you been told that you have vision loss that affects your ability to perform your sport? If YES, explain below. 5. Do you wear glasses? If yes, do you wear them during participation? Yes No 6. Do you wear contacts? If yes, do you wear them during participation? Yes No 7. Have you ever had an eye injury of any type? If YES, explain below. Page 3 of 9

4 VI. HEAD/NECK/FACE Have you suffered from, or been told (by a physician or your parents) you have/have had any of the following: Been Knocked Unconscious Frequent Headaches Suffered a Concussion. Migraines. Head Injury Frequent Dizziness.. Neck Injury. Frequent Nose Bleeds Pinched Nerve Nasal Blockage Burner/Stinger Nasal Fracture... Whiplash. Sinus Problems.... Chronic Neck Pain/Issues... Other... YES NO 1. Have you ever had a head/neck injury that has interrupted your athletic participation? If YES, how long were you inactive and explain: 2. Have you ever been hospitalized for a head injury? If YES, explain below. If YES, MONTH/YR 3. Have you ever been hospitalized for a neck injury? If YES, explain below... If YES, MONTH/YR 4. Have you ever been X-RAYED for a head or neck injury? If YES, explain. If YES, MONTH/YR below. VII. SKELETAL STRUCTURE Do you currently have or have you ever suffered from any of the following injuries: YES SHOULDER Separated Shoulder Dislocated Shoulder Burner/Stinger-Shoulder Shoulder Tendinitis/Tendinosis Shoulder Sprain/Strain Shoulder Fracture/Stress Fracture Shoulder Surgery Other Shoulder Injury: I ve never suffered a Shoulder Injury YES BACK Frequent Back Pain Injury to the Vertebral Column Back-Fracture/Stress Fracture Scoliosis SI Joint Dysfunction Herniated Disc Nerve Entrapment Back Surgery Other Back Injury: I ve never suffered a Back Injury Page 4 of 9

5 YES ELBOW Elbow Sprain/Strain Elbow Hyperextension Elbow Dislocation Elbow Fracture/Stress Fracture Elbow Tendinitis/Tendinosis Elbow Surgery Other Elbow Injury: I ve never suffered an Elbow Injury YES HIP Hip Fracture/Stress Fracture Groin Strains Hip Tendinitis/Tendinosis Hip Bursitis Snapping Hip Hip Surgery Other Hip Injury: I ve never suffered a Hip Injury YES WRIST/HAND/FINGERS Wrist/Hand/Finger Sprain/Strain Wrist/Hand/Finger Dislocation Wrist/Hand/Finger Tendinitis/Tendinosis Wrist/Hand/Finger Fracture Wrist/Hand/Finger Surgery Other Wrist/Hand/Finger Injury: I ve never suffered a W/H/F Injury YES LOWER LEG Shin Splints Lower Leg Tendinitis/Tendinosis Compartment Syndrome Lower Leg Stress Fracture/Fracture Lower Leg Surgery Other Lower Leg Injury: I ve never suffered a Lower Leg Injury YES ANKLE Sprained/Strained Ankle Achilles Tendon Injury Tendinitis/Tendinosis in the Ankle Ankle Fracture/Stress Fracture Ankle Dislocation Ankle Surgery Other Ankle Injury: I ve never suffered an Ankle Injury YES KNEE Knee Fracture Knee Dislocation Patellar Dislocation Meniscus Injury Knee Articular Cartilage Injury Knee Sprain/Strain Osgood-Schlatter's Disease Knee Tendinitis/Tendinosis Knee Surgery Other Knee Injury: I ve never suffered a Knee Injury YES FOOT Foot Sprain/Strain Foot Fracture/Stress Fracture Arch Problems Foot Tendinitis/Tendinosis Foot Surgery Other Foot Injury: I ve never suffered a Foot Injury YES TOE Turf Toe Morton s Neuroma Toe Fracture Toe Sprain/Strain Other Toe Injury: I ve never suffered a Toe Injury Page 5 of 9

6 VIII. EMOTIONAL Over the past two weeks, how often have you: Indicate your response utilizing the following scale: N- None or a little of the time S- Some of the time M- Most of the time A- All of the time Been feeling low in energy, slowed down Blamed yourself for things Had a poor appetite Had difficulty falling asleep, or staying asleep Been feeling hopeless about the future Been feeling blue Been feeling no interest in things Had feelings of worthlessness Thought about or wanted to commit suicide Had difficulty concentrating or making decisions During the past month, how much have you been bothered by each of the following symptoms of anxiety: Indicate your response utilizing the following scale: 0- Not at all 1- Mildly but it didn t bother me too much 2- Moderately it wasn t pleasant at times 3- Severely it bothered me a lot Numbness or tingling Unsteady Difficulty in breathing Feeling hot Terrified or afraid Fear of dying Wobbliness in legs Nervous Scared Unable to relax Feeling of choking Indigestion Fear of the worst happening Hands trembling Faint/lightheaded Dizzy or light headed Shaky/unsteady Face Flushed Heart pounding/racing Fear of losing control Hot/cold sweats Please respond to the following questions with a YES or NO response: YES NO 1. Do you make yourself sick because you feel uncomfortably full? 2. Do you worry that you have lost control over how much you eat? 3. Have you recently lost more than 15 pounds in a three month period? 4. Do you believe yourself to be fat when others say you are thin? 5. Would you say food dominates your life? Page 6 of 9

7 IX. FEMALE STUDENT-ATHLETES (FEMALES ONLY): 1. At what age did you have your first menstrual cycle? Days 2. How many days does your menstrual period last? Days 3. How many days between cycles? 4. How many periods have you had in the last 12 months? YES NO 5. Have you ever had irregular cycles? (shorter than 21 days or with more than 35 days between cycles) If Yes have you been seen by a physician to discuss this? YES NO 6. Have you ever had abnormally heavy bleeding? YES NO 7. Have you ever stopped having a period? If so, for how long? If yes, are you currently monitored by a gynecologist for this? YES NO 8. Do you or have you taken Birth Control Pills or Hormones? Type: X. ACKNOWLEDGEMENT I/We hereby certify that the above questions are answered to the best of our knowledge. Also, we understand this information will be used by the Athletic Medical Staff at Malone University to determine physical fitness to participate in intercollegiate athletics. Athlete's Signature*: Parent/Guardian Signature: If athlete is under the age of 18 Date: Date: *Hand written signature required Page 7 of 9

8 MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form PHYSICIAN PHYSICAL EXAM (To be completed by the athlete s physician) Athlete Name: LAST FIRST MI Sport(s): SSN: OPTIONAL Birthdate: MONTH / DAY / YEAR Height: FT IN Weight: POUNDS BP: / Pulse: Visual Acuity: Right / Left / Corrected: Yes or No (circle) Normal Abnormal Findings Initials MEDICAL Hearing Eyes/Ears/Nose/Throat Heart Heart Murmur Lungs Abdomen Lymph Nodes Genitalia (males only) Skin Femoral Pulses (to exclude Aortic Coarctation) Brachial Artery (sitting position) MUSCULOSKETAL: (please list any previous injuries or current findings) Neck Shoulder/Arm Wrist/Hand/Fingers Elbow/Forearm Back Hip/Thigh Knee Leg/Ankle Foot/Toes Physical Exam for Marfan Syndrome Gender: PHYSICAL EXAMINATION COMMENTS AND RECOMMENDATIONS: Are there any conditions/recommendations of which we should be aware? Describe fully. Use additional sheet if necessary: LABORATORY (OPTIONAL) (Recommended for long distance / endurance athletes) CBC with Iron Study Ferritin Blood test Page 8 of 9

9 MALONE SPORTS MEDICINE Pre-Participation Physical Exam Form PHYSICIAN PHYSICAL EXAM cont d (To be completed by the athlete s physician) Athlete Name: LAST FIRST MI Sport(s): PARTICIPATION RECOMMENDATIONS CLEARANCE Cleared with NO restrictions Cleared with restrictions including: Cleared AFTER completing evaluation / rehabilitation for: Not cleared for: REQUIRED BY ALL ATHLETES: Per NCAA guidelines, proof of Sickle Cell status MUST be attached to this physical form. Options for proof of status: 1. Sickle Cell testing is required at birth by many states. Depending on your state of birth, you may have already been tested. You may be able to obtain testing results from your pediatrician or the hospital where you were born. 2. Attach a copy current blood work showing sickle cell trait status. 3. Obtain the testing waiver from the Malone Sports Medicine website at waiving your right to testing. Please note: To enable us to provide you with the best medical care, it is HIGHLY recommended that you provide test results rather than waiving testing EXAMINER S CREDENTIALS (CIRCLE ONE): DO / MD *We CANNOT accept physicals performed by a chiropractor. Physician Name (Printed): Physician s Address: NUMBER STREET Physician Signature: CITY STATE ZIP CODE Date of Examination: / / 2018 Physician s Telephone Number: ( ) - *NOTE: Per NCAA guidelines, physical examinations MUST be performed within 6 months of the start date for the school year. Page 9 of 9