University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS

Transcription

1 Name (Last, First, MI) University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS of Birth Address Sex M / F Sport Phone City State Zip Please answer each question by checking the appropriate box. YES NO Have you ever had a pre-participation physical at UNO? Are you currently taking any medications, vitamins, or supplements? Please list all: Do you have any allergies to food/medications/other? Please list all: Has anyone in your family died suddenly before age 50? Has anyone in your family had a heart attack before age 50? Does your heart ever beat fast (racing heart) or skipped beats? Have you ever had chest pain, tightness, pressure or any discomfort during exercise? Have you ever been told that you have high blood pressure? Have you ever been told you have a heart murmur or any other heart problem? Have you ever passed out or fainted during exercise? Have you experienced any exercise-related heat illness, heat cramps, or heat stroke? Have you been diagnosed with asthma or exercise induced bronchial spasms? If yes, do you have a prescription inhaler? Y N Have you ever sustained a head injury of any type/severity? If yes, how many concussions have you had? What is the date of your most recent? Have you ever been knocked out, become unconscious or lost your memory? Were you evaluated by a physician? Have you ever had a seizure? Have you been hospitalized or had surgery within the last year? Do you have weakness, swelling, pain, numbness/tingling or previous injury in any of the following? Hand Upper Arm Foot Wrist Shoulder Ankle Elbow Neck Knee Forearm Spine Lower Leg Please Explain yes answers to questions #15 and #16 here. Thigh Hip Chest I hereby state that to the best of my knowledge, my answers to the above questions are complete & correct. Signature Parent/Guardian Signature (If under 19 years old)

2 University of Nebraska Omaha Athletic Performance Pre-Participation Medical History & Physical Examination Form TEAM TRYOUTS This portion is to be completed and signed by a Physician. Patient Name Age of Birth Height Weight Pulse Blood Pressure Vision Rt Lf Both Vision Corrected Rt Lf Both Pupils Equal Unequal Medical Normal Abnormal Comments Eyes/Ears/Nose/Throat Lymph Nodes Cardiovascular Chest & Lungs Abdomen Genatilia-Hernia Skin Orthopedic Normal Abnormal Comments Neck Back Shoulder/Upper/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Lower Leg/Ankle Foot CNS-Sensory/Reflexes/Coordination CLEARANCE Cleared NOT Cleared for Reason Recommendations The following information must be filled in & signed by either a Physician (M.D. or D.O.) or a Physician Assistant licensed by a State Board of Physician Assistant Examiners. Examination forms signed by any other health care practitioner will not be accepted. Physician Name of Examination Hospital/Clinic Name Phone Number Address Physician Signature

3 University of Nebraska Omaha - Athletic Performance Sickle Cell Trait Form Student-Athlete Name Sport NU-ID or last 4 of SSN # 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 predominant in African-Americans and those of Mediterranean, Middle Easter, 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 starved of blood. Sickle Cell Trait Testing The NCAA mandates that all NCAA Division I student-athletes must a) be tested for sickle cell trait, b) show proof of a prior test, or c) sign a waiver releasing an institution from liability if they decline to be tested before the student-athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc. The University of Nebraska Omaha Department of Intercollegiate Athletics offers sickle cell trait screening in the form of a blood test to all Division I student-athletes as part of the pre-participation physical exam process. The cost of the testing is the responsibility of the studentathlete. Testing will be conducted at the University of Nebraska Omaha Student-Health Services Center and/or other designated laboratory facility and results will be reported to the University of Nebraska Omaha Head Athletic Trainer. If a student-athlete does not wish to have the test performed, that student-athlete must either a) show proof of a previous sickle cell trait test confirming their status, or b) sign the sickle cell testing waiver below. Place Your Initials By ONE Of The Following: I acknowledge that I have read the above information and WOULD LIKE TO BE TESTED for the sickle cell trait (you will be contacted by a member of the athletic training staff regarding the date and time of this test). _ I HAVE BEEN TESTED and agree to provide proof of my sickle cell trait status. I understand that I will not be allowed to participate in activities at UNO until I provide this documentation. I acknowledge that I have read the above information and DO NOT WANT TO BE TESTED FOR SICKLE CELL TRAIT (must sign waiver below). SICKLE CELL TRAIT TESTING WAIVER I,, understand and acknowledge that the NCAA and the Student-Athlete Name The University of Nebraska Omaha Department of Intercollegiate Athletics mandate 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 the University of Nebraska Omaha Athletic Performance 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 the State of Nebraska, the University, its officers, 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 mandate of the NCAA and the University of Nebraska Omaha Department of Intercollegiate Athletics. I have read and signed this document with full knowledge of its significance. I further state that I am at least 19 years of age and competent to sign this waiver. Student-Athlete Signature Parent/Guardian Signature (if under 19 years of age) Parent/Guardian Print Name

4 University of Nebraska Omaha - Athletic Performance Release for Athletic Participation Form Release made this day of, 20 by the student- athlete named,. In consideration of permission granted to me by the University of Nebraska Omaha to participate in the UNO Varsity Sports program, I hereby release and discharge the Board of Regents of the University of Nebraska, the University of Nebraska Omaha, their agents, employees, and officers (the Released ), from all claims, demands, actions, judgments, and executions which the undersigned ever had, or now has, or may have, or which the undersigned s heirs, executors, administrators, or assigns may have, or claim to have, against the released (real or personal), caused by, or arising out of, my participation in the UNO Varsity Sports program. I hereby assume full responsibility for the risk of bodily injury, death or property damage while competing, practicing or engaging in any other activity associated with my participation in the UNO Varsity Sports program. I have read this release and understand all its terms. I execute it voluntarily with full knowledge of its significance and actual knowledge of the dangers posed and voluntarily expose myself to the risk of injury by my participation in the UNO Varsity Sports Program. I hereby expressly agree at all times in practice and competition and to take such actions as may be deemed reasonable to protect myself from injury. I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the Sate of Nebraska and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. IN WITNESS WHEREOF, I have executed this release in date and year first written above., Nebraska on the (Student Athlete Signature) (Parent or Guardian Signature if athlete is under age 19)

5 TRY-OUT CLEARANCE FORM OMAHA COMPLIANCE STUDENT INFORMATION NOTICE: Any individual cleared to practice is for a 14-day tryout period only. Coaches must notify the Athletic Compliance Office when a determination has been made as to this try-out s status. Coaches must complete a Late Addition to Team Roster Form when a try-out SA is to be added to a roster. Unless a student is added to the roster, all students trying out must cease practice at the end of the 14-day tryout period. Name: Sport: NU ID: Birth : - - Have you played collegiately for any team/school in the past (including club teams)? Yes No If yes, what sport(s)? List all Semester(s)/Year(s)? ATHLETIC TRAINING PHYSICAL EXAM/LIABILITY CHECK: Has the above student has submitted the following information? Proof of Physical Proof of Sickle Cell Testing & Results Proof of Medical/Health Insurance Release for Athletic Participation Form Student is cleared for a 14-day tryout period only. Athletic Trainer UNO Enrollment: Fall Spring Year: Yes No Enrolled full-time (12 hours) at UNO? Yes No Attended prior institution full-time? Type of Transfer (check one): 4-Year 2-Year Year PRELIMINARY ELIGIBILITY ATHLETIC COMPLIANCE OFFICE Director of Compliance Sapp Fieldhouse 221 NCAA Eligibility (45-day grace period to complete) Registered with NCAA Eligibility Center? Yes No IE Status (check one): Amateur Status (check one): Qualifier Final Certified Non-Qualifier Preliminary Certified Pending/No Decision Not Certified Not Registered Practice Start : Is the student within his/her five-year eligibility clock (Bylaw )? Yes No Is the student a transfer (Bylaw 14.5)? Yes No Transfer Tracer sent to previous institution? Yes No N/A If 4-4, did UNO get permission to contact or a year elapsed since withdrawn (Bylaw )? Yes No N/A Has SA been evaluated (Incoming Transfer Academic Eligibility Assessment) been conducted? Yes No N/A CLEARED FOR TRY-OUT NOT CLEARED FOR TRY-OUT Compliance Office: : Copy to: Coach(es), Athletic Training, Compliance