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1 Dear Student-Athlete, Welcome to Widener University. In order to keep you safe on and off the field there are certain requirements you must fulfill before participating in collegiate sports. Please see below for requirements. 1. Athletic History and Pre-Participation Physical Must be completed within 6 months prior to the first sanctioned practice This examination will be performed by a health care provider of the student s choice and paid for at the student s expense If within the last 12 months any major illness/injury/ surgery/hospitalization/tbi/concussion has occurred, additional documentation is required including: treating provider(s), diagnosis, treatment and ability to participate in sports All incoming BASKETBALL players are required to have an EKG completed as part of their athletic physical Upon review of athletic physical you may be required to submit additional documentation for clearance 2. Sickle Cell Trait Testing All student-athletes must provide results of sickle cell trait testing this test may have been performed at birth or can be completed at a doctor s office or Student Health Services for a fee 3. Banned Prescription Medication Exemption Form Any student-athlete must provide adequate documentation of diagnosis and treatment of conditions requiring the use of banned substances, including (but not limited to) stimulant use for ADHD/ADD In order to allow for a medical exemption for athlete s use of stimulant medication please provide your medical provider with the attached medical exemption form (page 6) All elements of this athletic history and pre-participation physical exam must be sent to Widener University Student Health Services postmarked no later than June 25, Please note failure to comply will result in the inability to participate. Please submit all forms to: Widener University Student Health Services One University Place Chester, PA Fax: Studenthealth@widener.edu 1

2 Name: Date of Birth: Sport: Medical History (Personal) Exertional chest pain/discomfort YES NO YEAR IF YES, PROVIDE EXPLANATION Unexplained syncope/fainting or near syncope Prior diagnosis of heart murmur Elevated blood pressure Prior restriction from sports due to cardiac issue(s) Prior testing for the heart - EKG, Echocardiogram *Copies must be attached* Arrhythmias or irregular heartbeat Heart disease, cardiomyopathy or Marfan s Syndrome Fatigue or shortness of breath while exercising Asthma Diabetes Seizures TBI/concussions/head injury How many Dates Migraines Chronic illness(es) Eating disorder Mental health or psychological issues Anemia or bleeding disorders (i.e. sickle cell) ADHD/ADD/learning disability Loss of a paired organ 2

3 Name: Date of Birth: Sport: Medical History (Personal) Musculoskeletal Injuries/Fractures Sprain/strain YES NO YEAR IF YES, PROVIDE EXPLANATION AND LOCATION(S) Tear Tendonitis Fracture Dislocation X-ray CT Scan MRI Injection Rehabilitation Allergies to any medications, food or latex? (Please circle none or list if applicable) NONE Medication, food or latex Current Medications (Please circle none or list if applicable) Reaction NONE Surgeries and Hospitalizations (Please circle none or list if applicable) NONE 3

4 Name: Date of Birth: Sport: Family Medical History Sudden, unexplained or cardiac death before age of 50 YES NO RELATION IF YES, PROVIDE EXPLANANTION Heart disease under the age of 50 Heart attack under the age of 50 Hypertrophic or dilated cardiomyopathy Long- QT syndrome, Wolff-Parkinson White Syndrome, or Brugada Syndrome High blood pressure Anemia or bleeding disorders (i.e. sickle cell) 4

5 This form to be completed by a medical provider Name: Date of Birth: Sport: Height (in): Weight (lbs): Pulse: Vision: R 20/ L 20/ Corrected: Y or N Brachial artery blood pressure, sitting: / MEDICAL Appearance - Evidence of Marfan s Syndrome NORMAL ABNORMAL FINDINGS Eyes/Ears/Nose/Throat PERRLA, EOMI Lymph Nodes Cardiac - Murmurs (standing, supine, +/- Valsalva, squatting) Pulses (Bilateral femoral pulses to exclude aortic coarctation) Lungs Abdomen - bowel sounds, tenderness, liver, spleen, hernia Skin - Lesions suggestive of MRSA, HSV, Tinea or Impetigo Neurological - CN II-XII, DTR s MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Hip/Thigh Knee CLEARANCE- I certify that I have reviewed personal and family history for student athlete Cleared for physical activity and sports without any restrictions Cleared for physical activity and sports but with restrictions (list below) Restrictions/Limitations NOT cleared Provider s Signature: MD, DO, CRNP, PA-C Date of Exam: Office Stamp: (Required) 5

6 Stimulant Medication Guidelines and Requirements Please return this form with all required documentation Student Athlete Name Date of Birth Student ID # Sport Widener University Athletic Department in conjunction with the NCAA Medical Exemption Banned stimulant policy requires strict documentation of the use of stimulant medications. This documentation must demonstrate that the student athlete has had a clinical assessment, being monitored routinely for use of stimulant medication, and has a current prescription on file in Student Health Services to be approved for a medical exemption to the banned drug policy. Clinical Evaluation and documentation must include the following: Please initial each space to confirm that the information is included in the report Summary of comprehensive evaluation (referencing DSM-IV, attach all documentation) ADHD/ADD Rating scale(s) (i.e. Connors, ASRS, CAARS) scores/report summary Statement of Diagnosis (including when it was confirmed) History of Treatment (previous/ongoing) List all current medication(s) and dosages Blood pressure/pulse readings, H & P and exam date (attach supporting documentation) Laboratory/testing results Date/results of most recent clinical evaluation Follow-up and ongoing plan of care A student athlete signed note that documents that alternative non-banned medications have been considered Copy of current voided stimulant prescription Stimulant Use Fact Sheet used by provider s practice (attach copy) Provider s policy for stimulant misuse; lost or stolen stimulant prescription (attach copy) Provider s Name (printed) Provider s Signature, date and credentials Office Stamp: 6

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