Dear Student-Athlete,

Transcription

1 Dear Student-Athlete, Welcome to Widener University. In order to keep you safe on and off the field there are certain physical requirements you must fulfill before participating in club sports. Please see below for requirements. 1. Athletic History and Pre-Participation Physical Must be completed yearly. New club sport students must have their first pre-participation physical within 6 months prior to the first practice. This examination will be performed by a health care provider of the student s choice and paid for at the student s expense Pages 2-4 of the History and Pre-Participation form are selfreporting and page 5 is to be filled out by the medical provider. Please bring the entire packet so the medical provider can review the personal and family history before completing exam. 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 Upon review of athletic physical you may be required to submit additional documentation for clearance. 2. Impact Testing Must be completed prior to first practice To be completed at Student Health Services- call to make an appointment for this All elements of this athletic history and pre-participation physical exam must be sent to Widener University Student Health Services in order to participate in club sports. 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 Widener University Athletic History and Pre-Participation Physical Form Name: Date of Birth: Sport: Medical History (Personal) TO BE COMPLETED BY STUDENT ATHLETE 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 *Documentation required for TBI in last 12 months* Migraines How many Dates Chronic illness(es) Eating disorder Mental health or psychological issues Anemia or bleeding disorders (i.e. sickle cell) ADHD/ADD/learning disability 2

3 Loss of a paired organ Widener University Athletic History and Pre-Participation Physical Form Name: Date of Birth: Sport: Medical History (Personal) TO BE COMPLETED BY STUDENT ATHLETE Musculoskeletal Injuries/Fractures Muscle Strain YES NO YEAR IF YES, PROVIDE EXPLANATION AND LOCATION(S) Joint Sprain 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 Widener University Athletic History and Pre-Participation Physical Form Name: Date of Birth: Sport: Family Medical History TO BE COMPLETED BY STUDENT ATHLETE 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 Widener University Athletic History and Pre-Participation Physical Form 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: 5

6 Office Stamp: 6