Upper Iowa University Athletic Training. Name: Last First Middle. Home Address: Street Address City State Zip
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1 Upper Iowa University Athletic Training MEDICAL HISTORY Personal Data Name: Last First Middle Home Address: Street Address City State Zip School Address: Street Address City State Zip Home Phone #: Cell Phone #: Address: Social Security #: Date of Birth: Gender: Fr /So /Jr /Sr/ 5 th yr: Sport(s): In Case of Emergency, Notify: Name: Address: Last First Home Address: Relationship: Street Address City State Zip Home Phone #: Work Phone #: Cell Phone #: Current Medications/Supplements/Birth control: List prescription or over-the-counter and if there are more than three list on a separate sheet of paper and notify your Certified Athletic Trainer. List: Name Dosage Prescribing doctor Reason for use Immunization: Most recent. Tetanus: HBV: MMR: : Family History: Has anyone in your immediate family had? If marked yes explanation is required with dates: Sudden Death (Before 50) Heart Disease/Heart Attack Heart Murmur Abnormal Heart Rate/Palpitation High Blood Pressure/Hypertension Diabetes Marfan Syndrome Epilepsy Blood Disorder 1
2 Personal Medical History: Have you ever had/currently have any of the following conditions? ADD/ADHD Anemia/Low Blood Counts Appendicitis Asthma/Breathing Problems* Chicken Pox Constipation/Diarrhea/Hemorrhoids Eating Disorder (anorexia, bulimia) Emotional Disturbance (Depression / Anxiety) Epilepsy/Seizure Disorder Hearing Impairment/Loss Hernia Hepatitis/Liver Problems/Jaundice Kidney Disease/Stones/Injury Migraine/Headaches Missed a game due to illness Menstrual Irregularities Mononucleosis Pins/Staples/Wires/Screws in body Pneumonia/Frequent Respiratory Infections Recurrent Ear Infections Sexually Transmitted Disease Sinus Infection/Nasal Polyps/Nose Fracture Spleen/Liver Injury Stomach Problems (bleeding, ulcers) Stress Fracture Thyroid Disorder Tuberculosis Tumor/Growth/Cyst Urinary Problems (blood, recurrent infections) Human Immunodeficiency Virus (HIV) * If you have an inhaler for Asthma/Breathing problems or any emergency medications; bring an extra to your Certified Athletic Trainer prior to the start of team activities. Internal/Surgical History: Were you born WITHOUT a complete set of organs (eyes, kidneys, ovaries/testes, etc )? Have you ever had to repair / remove any organ (hernia, tonsils, appendix, spleen, etc )? Allergies: Aspirin Anti-Inflammatories Codeine Hay Fever Insect Stings/Bites Latex Penicillin Sulfa Any Foods If you have an epi-pen or any emergency medications for your allergies; bring extra to your Certified Athletic Trainer prior to the start of team activities. Cardiac History: Have you ever had/currently have any of the following conditions? High blood pressure/hypertension Irregular heart beat/palpitations Felt dizzy/light-headed/passed out during or after exercise? Have seen a cardiologist Rheumatic heart disease Had an echocardiogram/ekg Had a stress test? Chest pain/tightness/discomfort with Heart Murmur exercise? Easily fatigued Exertional shortness of breath 2
3 Heat Illness History: Have you ever? Become dehydrated Had heat cramps Had heat exhaustion Had heat stroke Received IV fluids Had an intolerance to heat **Vision History: Have you ever/do you currently: Had an eye injury Wear glasses/contacts/protective eyewear Have you had an eye exam in the last year Diabetes: Have you ever/do you currently: Have diabetes Have complications with your diabetes Do you have an insulin pump Dental History: Have you ever/do you currently: Had a tooth knocked out/loose/chipped Wear a dental appliance Wear a protection device Sickle Cell Disease: Have you ever/do you currently: Have sickle cell disease Have sickle cell trait Have you been tested for sickle cell trait Have a family history of sickle cell **If you have contacts or glasses please bring a copy of your prescription to your Certified Athletic Trainer. If you wear contacts please bring an extra pair to your ATC so we have them in case one is lost, destroyed, and for road trips. Please describe below any further general medical information which is knowledgeable to you and has not been requested. Orthopedic History Head Injury: Have you ever had/currently have: Concussion Knocked out/unconscious Recurrent headaches/migraines Fracture X-ray/CT/MRI Cervical Spine/Neck: Have you ever had/currently have: Disc injury Pinched nerve/stinger in arms or legs in arms or legs 3
4 Shoulder/Upper Arm: Have you ever had/currently have: /Subluxation Shoulder Separation Elbow/Forearm: Have you ever had/currently have: Wrist/Hand/Finger: Have you ever had/currently have: Spine/Low Back: Have you ever had/currently have: Nerve/Disc Injury in leg Pain in leg in leg Ribs/Chest: Have you ever had/currently have: 4
5 Hip/Groin: Have you ever had/currently have: Thigh: Have you ever had/currently have: Fracture Knee: Have you ever had/currently have: /Subluxation Torn cartilage/meniscal injury Swelling Locking/Giving away Ankle/Lower Leg: Have you ever had/currently have: Instability Stress Fracture/Shin Splints Foot/Toe: Have you ever had/currently have: 5
6 Please describe below any further medical information which is knowledgeable to you and has not been requested. The undersigned, hereby: I, the undersigned, hereby acknowledge, affirm, and represent that all statements are true and accurate to the best of my knowledge; and that no answers or information have been withheld. I fully understand that UIU, its agents, servants, trustees, and employees disclaim liability for any previous medical condition, whether included or omitted on this form, and will not be held liable for any injuries and/or illnesses. I further understand that having passed the physician examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the examiner did not find any medical reason to disqualify me. Student-Athlete Printed Name Student-Athlete Signature Date If under 18, a parent/guardian must sign as well. Parent / Guardian Printed Name Parent / Guardian Signature Date I acknowledge and understand by typing my name in the signature blanks, I am submitting my signature and have read and understand the information on this form. 6
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MARINA HS SPORTS PHYSICALS WHEN May 30 th, 2018 @ 4pm8pm WHERE Marina Gymnasium COST $30 cash or check WHAT TO BRING Peach PHYSICAL FORM (with front side filled out) $30 CASH or CHECK made out to Marina
Date: New Patient Form First Visit Date:
Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
Medical Health Information (continued):
Patient s Name (please print): Date: / / Medical Health Information (continued): The following questions are for your benefit and assure that treatment will take into consideration your past and present