ATHLETE REGISTRATION AND SPECIAL OLYMPICS NEW JERSEY MEDICAL POLICY

Transcription

1 ATHLETE REGISTRATION AND SPECIAL OLYMPICS NEW JERSEY MEDICAL POLICY Prior to participating in any Special Olympics training or competition program, an athlete or parent/guardian of an athlete must complete the official PARTICIPANT RELEASE FORM and ATHLETE MEDICAL FORM. When completed correctly, these forms located on our website, provide medical history, insurance information (secondary insurance coverage is provided by Special Olympics, Inc.), emergency contact information in the event a parent/guardian cannot be reached, pre-participation physical exam by a licensed medical professional, and a release form that includes information regarding housing, the use of photos, and our policy on concussion awareness. SPECIAL OLYMPICS NEW JERSEY ATHLETE MEDICAL FORM Prior to participating in any Special Olympics program, pages 1 and 2 (Health History Form) must be completed by someone with knowledge of the medical history of the athlete. The form must be completed as accurately as possible and must contain the name, relationship and contact information of the person completing the form on the bottom shaded portion of page 2. Pages 3 and 4 (Physical Exam) must be completed by a licensed health care professional authorized to complete the examination (M.D., D.O., APRN, PA,C). The shaded portions (MEDICAL PHYSICAL INFORMATION and RECOMMENDATIONS) must be completed, and the signature, date of exam, and information of the licensed health care provider must be included on the bottom of page 3, or the forms will be returned. Page 4 only needs to be completed if the licensed health care provider requires a referral (which would be indicated as such on page 3). The Participant Release Form, must include the participant s name, and be signed AND dated by the athlete and/or parent/guardian. If either box is checked under "Emergency Care", the appropriate Emergency Care Refusal Form must be completed and submitted with the packet. These forms may be found in the "Locker Room" section of the website. The Concussion Awareness Policy may be retained by the participant. Any of the above forms that are incomplete will be returned to the athlete/parent/guardian, and that athlete will not be permitted to participate until all forms have been correctly submitted. The PARTICIPANT RELEASE FORM and ATHLETE MEDICAL FORM must be completed every three years unless your physician requires yearly examinations, or there is a significant change to the health of the participant. The forms may be completed yearly if the parent/guardian chooses. A medical form is valid for three years from the Date of Exam. [Example Athlete participating in swimming has a date of exam of 6/1/2014, it therefore expires 6/1/2017. Summer Games is scheduled for 6/10/2017. The athlete may participate in Area and Sectional competition, BUT will not be permitted to attend Summer Games without a new physical.] Once expired, a new set of forms must be completed correctly and forwarded to SONJ PRIOR to participation in any new training activity. Official Participant Release and Athlete Medical Forms are available both on the SONJ website as well as at the SONJ Complex. Completed forms may be mailed to the rea irector of the county in which you reside. lease click ERE for your rea irector contact information. lease contact oanne Monaco at M son.org if you ha e any uestions regarding the form.

2 Athlete Medical Form HEALTH HISTORY (pages 1 & 2 to be completed by the athlete or parent/guardian/caregiver) AREA: T : ATHLETE INFORMATION PARENT GUARDIAN INFORMATION (if not own guardian) First Name: Middle Name: Name: Last Name: Phone: Cell: Date Birth (mm/dd/yyyy) : Female: Male: Address (Street): Emergency Contact Name: Same as Above: Address (City, State, Zip): Emergency Contact Phone (cell): Phone: Cell: Emergency Contact Relationship: Does the athlete have a primary care physician? If yes, list. Eye color: Ethnicity: (optional) Physician Name: Physician Phone: Athlete Employer, if any: Insurance Policy (Company and Number): I am my own guardian. Does the athlete have any objections to emergency medical care? If yes, contact your local Program to get the Emergency Care Refusal Form. Does the athlete have (check any that apply): Autism Down syndrome Fragile X Syndrome List any sports the athlete wishes to play: Cerebral Palsy Fetal Alcohol Syndrome Other syndrome, please specify: Is the athlete allergic to any of the following (please list): Has a doctor ever limited the athlete s participation in sports? If yes, please describe: Latex Known Allergies Medications: Insect Bites or Stings: Food: List any special dietary needs: Does the athlete use (check any that apply): Brace Colostomy Communication Device C-PAP Machine Crutches or Walker Dentures Glasses or Contacts G-Tube or J-Tube Hearing Aid List all past surgeries: Does the athlete currently have any chronic or acute infection? If yes, please describe: Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)? If yes, select below and describe, had abnormal EKG, had abnormal Echo Implanted Device Inhaler Pacemaker Removable Prosthetics Splint Wheel Chair Has the athlete had a Tetanus vaccine in the past 7 years? FAMILY HISTORY Has any relative died of a heart problem before age 50? Has any family member or relative died while exercising? List all medical conditions that run in the athlete s family: Medical Form for US Programs updated June 2016 Special Olympics Medical Form 1 of 4

3 Athlete Medical Form HEALTH HISTORY (pages 1 & 2 to be completed by athlete or parent/guardian/caregiver) Athlete s Name: HAS THE ATHLETE EVER BEEN DIAGNOSED WITH OR EXPERIENCED ANY OF THE FOLLOWING CONDITIONS Loss of Consciousness High Blood Pressure Stroke/TIA Dizziness during or after exercise High Cholesterol Concussions Headache during or after exercise Vision Impairment Asthma Chest pain during or after exercise Hearing Impairment Diabetes Shortness of breath during or after exercise Enlarged Spleen Hepatitis Irregular, racing or skipped heart beats Single Kidney Urinary Discomfort Congenital Heart Defect Osteoporosis Spina Bifida Heart Attack Osteopenia Arthritis Cardiomyopathy Sickle Cell Disease Heat Illness Heart Valve Disease Sickle Cell Trait Broken Bones Heart Murmur Easy Bleeding Dislocated Joints Endocarditis Difficulty controlling bowels or bladder Describe any past broken bones or dislocated joints (if yes is If yes, is this new or worse in the past 3 years? checked for either of those fields above): Numbness or tingling in legs, arms, hands or feet If yes, is this new or worse in the past 3 years? Weakness in legs, arms, hands or feet Epilepsy or any type of seizure disorder If yes, is this new or worse in the past 3 years? Burner, stinger, pinched nerve or pain in the neck, back, shoulders, arms, hands, buttocks, legs or feet If yes, list seizure type: If yes, had seizure during the past year? If yes, is this new or worse in the past 3 years? Self-injurious behavior during the past year Head Tilt Aggressive behavior during the past year If yes, is this new or worse in the past 3 years? Depression (diagnosed) Spasticity Anxiety (diagnosed) If yes, is this new or worse in the past 3 years? Describe any additional mental health concerns: Paralysis If yes, is this new or worse in the past 3 years? List any other ongoing or past medical conditions: PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW (includes inhalers, birth control or hormone therapy) Medication, Vitamin or Supplement Dosage Times per Day Medication, Vitamin or Supplement Dosage Times per Day Medication, Vitamin or Supplement Dosage Times per Day Is the athlete able to administer his or her own medications? If female athlete, list date of last menstrual period: Name of Person Completing this Form Relationship to Athlete Phone Medical Form for US Programs updated June 2016 Special Olympics Medical Form 2 of 4

4 This event is not sponsored or endorsed by or under the auspices of the Athlete Medical Form PHYSICAL EXAM (to be completed by a Medical Professional only) Athlete s Name: MEDICAL PHYSICAL INFORMATION (TO BE COMPLETED BY EXAMINER ONLY) Height Weight cm BMI (optional) kg Temperature BMI Pulse O2Sat Blood Pressure C BP Right: Vision BP Left: Right Vision N/A N/A 20/40 or better in lbs Body Fat % F Left Vision 20/40 or better Right Hearing (Finger Rub) Responds Response Can t Evaluate Bowel Sounds Left Hearing (Finger Rub) Responds Response Can t Evaluate Hepatomegaly Right Ear Canal Cerumen Foreign Body Splenomegaly Left Ear Canal Cerumen Foreign Body Abdominal Tenderness RUQ RLQ Right Tympanic Membrane Perforation Infection NA Kidney Tenderness Right Left Left Tympanic Membrane Perforation Infection NA Right upper extremity reflex rmal Oral Hygiene Good Fair Poor Left upper extremity reflex rmal Thyroid Enlargement Right lower extremity reflex rmal Lymph de Enlargement Left lower extremity reflex rmal Heart Murmur (supine) 1/6 or 2/6 3/6 or greater Abnormal Gait, describe below Heart Murmur (upright) 1/6 or 2/6 3/6 or greater Spasticity, describe below Heart Rhythm Regular Irregular Tremor, describe below Lungs t clear Neck & Back Mobility t full, describe below Right Leg Edema Upper Extremity Mobility t full, describe below Left Leg Edema Lower Extremity Mobility t full, describe below Radial Pulse Symmetry R>L Upper Extremity Strength t full, describe below Cyanosis, describe Lower Extremity Strength t full, describe below Clubbing, describe Loss of Sensitivity, describe below L>R LUQ LLQ ATLANTO-AXIAL INSTABILITY (AAI) Athlete shows NO EVIDENCE of neurological symptoms or physical findings associated with spinal cord compression or atlantoaxial instability. Athlete has neurological symptoms or physical findings that could be associated with spinal cord compression or atlantoaxial instability and must receive an additional neurological evaluation to rule out additional risk of spinal cord injury prior to clearance for sports participation. RECOMMENDATIONS (TO BE COMPLETED BY EXAMINER ONLY) Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to performing the physical exam. If an athlete needs further medical evaluation please use the Special Olympics Further Medical Evaluation Form, page 4, to provide the athlete with medical clearance.. This athlete is ABLE to participate in Special Olympics sports without restrictions/limitations This athlete is ABLE to participate in Special Olympics sports WITH restrictions/limitations This athlete MAY NOT participate in Special Olympics sports at this time and MUST be further evaluated by a physician for the following concerns: Concerning Cardiac Exam Acute Infection O2 Saturation Less than 90% on Room Air Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly Other, please describe: Additional Licensed Examiner s tes and Recommended Follow-up: Follow up with a cardiologist Follow up with a neurologist Follow up with a primary care physician Follow up with a vision specialist Follow up with a hearing specialist Follow up with a dentist or dental hygienist Follow up with a podiatrist Follow up with a physical therapist Follow up with a nutritionist Other/Exam tes: Name: Licensed Medical Examiner s Signature Medical Form for US Programs updated June 2016 Date of Exam Phone: License: Special Olympics Medical Form 3 of 4

5 This event is not sponsored or endorsed by or under the auspices of the Athlete Medical Form MEDICAL REFERRAL FORM (to be completed by a Medical Professional only if referral is needed) Athlete s Name: This page only needs to be completed and signed if the physician on page three does not clear the athlete and indicates follow-up is required. Athlete should bring the previously completed pages to the appointment with the specialist. Examiner s Name: Specialty: I have examined this athlete for the following medical concern(s): Please describe In my professional opinion, this athlete MAY participate in Special Olympics sports (indicate restrictions or limitations below):, without restrictions, but with restrictions (list below) Additional Examiner tes/restrictions: Examiner Examiner Phone: License: Examiner s Signature Date This section to be completed by Special Olympics staff only, if applicable. This medical exam was completed at a MedFest event? The athlete is a Unified Partner or a Young Athlete Participant? Medical Form for US Programs updated June 2016 Unified Partner Young Athlete Special Olympics Medical Form 4 of 4

6 PARTICIPANT RELEASE FORM New Jersey I want to participate in Special Olympics activities and agree to the following: 1. Able to Participate. I am able to participate in Special Olympics activities. I understand that there is a risk of injury when participating in Special Olympics activities. 2. Photo Release. I give Special Olympics organizations permission to use my picture, video, name, voice, and words to promote Special Olympics. 3. Overnight Stay. I understand that some Special Olympics activities may require an overnight stay in a hotel or someone else s home. Any questions may be referred to the SONJ housing policy. 4. Emergency Care. I consent to medical care if needed in an emergency, unless I check one of these boxes: I have a religious or other objection to receiving medical treatment. I consent to emergency medical care, but I do not consent to blood transfusions. (If either box is checked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.) 5. Health Programs. If I choose to participate in a Special Olympics health program, I consent to health-related activities, physical examinations, and treatment. I understand that this should not replace regular medical care. I understand that I can stop participating or say no to treatment or any other activity any time. 6. Personal Information. I understand that my personal information may be used and shared by employees and volunteers of Special Olympics organizations to: Make sure I am eligible and can participate safely in Special Olympics activities; Coordinate training and competition events and publish competition results; Put my information into a computer database maintained by Special Olympics; Provide healthcare treatment, make referrals, consult doctors, and remind me about follow-up services; Research, communicate, and respond to needs of Special Olympics participants (identifying information is removed if shared with the public); and Protect health and safety, respond to government requests, and report information as required by law. I understand I can ask to see and revise my personal information and to limit how my information is used. 7. Concussion Awareness and Safety Policy. I have read the policy and understand the return to play requirements as outlined on the reverse side of this form. PARTICIPANT NAME: PARTICIPANT SIGNATURE (required if Participant is over 18 years old and is signing on own behalf) I have read and understand this release. If I have any questions, I will ask. By signing, I agree to this release. Participant Signature: Date: PARENT/GUARDIAN SIGNATURE (required if Participant is under 18 years old or has a legal guardian) I am a parent or guardian of the Participant. I have read and understand this form and have explained the contents to the Participant as appropriate. By signing, I agree to this form on my own behalf and on behalf of the Participant. Parent/Guardian Signature: Date: Printed Name: Relationship: Updated May, 12, 2016

7 CONCUSSON AWARENESS AND SAFETY RECOGNITION POLICY Objective It is Special Olympics intent to take steps to help ensure the health and safety of all Special Olympics participants. All Special Olympics participants should remember that safety comes first and should take reasonable steps to help minimize risks for concussion or other serious brain injuries. Defining a Concussion A concussion is defined by the Centers for Disease Control as a type of traumatic brain injury caused by a bump, blow, or jolt to the head as well as serial, cumulative hits to the head. Concussions can also occur from a blow to the body that causes the head and brain to move quickly back and forth causing the brain to bounce around or twist within the skull. Although concussions are not usually life-threatening, their effects can be serious and therefore proper attention must be paid to individuals suspected of sustaining a concussion. Suspected or Confirmed Concussion Effective immediately, a participant who is suspected of sustaining a concussion in practice, game or competition shall be removed from practice, play or competition at that time. If a qualified medical professional is available on-site to render an evaluation, that person shall have final authority as to whether or not a concussion is suspected. If applicable, the participant s parent or guardian should be aware that the participant is suspected of sustaining a concussion. Return to Play A participant who has been removed from practice, play or competition due to a suspected concussion may not participate in Special Olympics sports activities until either of the following occurs (1) at least seven (7) days have passed since the participant was removed from play and a currently licensed, qualified medical professional provides written clearance for the participant to return to practice, play and competition, or (2) a currently licensed, qualified medical professional determines that the participant did not suffer a concussion and provides written clearance for the participant to return to practice, play immediately. Written clearance in either of the scenarios above shall become a permanent record. 2 Special Olympics New Jersey