We confirm that the above insurance information is correct.

Transcription

1 ATHLETE INFORMATION AND HEALTH QUESTIONNAIRE MISSOURI STATE UNIVERSITY SECTION 1 STUDENT-ATHLETE DEMOGRAPHIC INFORMATION FULL LEGAL NAME: Last: First: MI SS#: SPORT: DATE OF BIRTH: HOME PHONE: CELL PHONE: PERMANENT HOME ADDRESS: Street: City: State: Zip Code: ADDRESS: SECTION 2 PARENT DEMOGRAPHIC INFORMATION FATHER: SOCIAL SECURITY # DATE OF BIRTH: ADDRESS: HOME PHONE: CELL PHONE: HOME ADDRESS: MOTHER: SOCIAL SECURITY # DATE OF BIRTH: ADDRESS: HOME PHONE: CELL PHONE: HOME ADDRESS: SECTION 3 INSURANCE INFORMATION (PLEASE BRING YOUR INSURANCE CARD AT YOUR PHYSICAL) ARE YOU COVERED BY AN INSURANCE POLICY? IS THERE A DENTAL PLAN INCUDED? IF YES, WHO IS THE POLICY HOLDER? IS THERE A PHARMACY PLAN INCLUDED? IS IT A GROUP MEDICAL PLAN THROUGH AN EMPLOYER? DO YOU HAVE A SECONDARY INSURANCE POLICY? We confirm that the above insurance information is correct. Policy Holder: Athlete: Appropriate Signatures Required PRINT NAME SIGNATURE DATE We confirm that this athlete has no insurance coverage. Father: Mother: Athlete: Appropriate Signatures Required PRINT NAME SIGNATURE DATE We acknowledge that, in accordance with the MSU policy, our insurance is considered the primary payer and MSU coverage secondary; for all medical expense incurred which fall within the MSU policy for coverage. Whatever falls outside Missouri State University policy for coverage, we assume financial responsibility for. Appropriate Signatures Required We agree with the above statement. Policy Holder: Athlete: PRINT NAME SIGNATURE DATE

2 SECTION 4 FAMILY MEDICAL HISTORY IMMEDIATE FAMILY AGE LEVEL OF HEALTH IF DECEASED, LIST AGE AT TIME OF DEATH and CAUSE OF DEATH FATHER MOTHER SIBLING 1 SIBLING 2 SIBLING 3 SIBLING 4 SIBLING 5 SIBLING 6 HAS ANY RELATIVE EVER HAD? Please mark an X to all those that apply. CONDITION X RELATION CONDITION X RELATION CANCER HIGH BLOOD PRESSURE TUBERCULOSIS STROKE DIABETES EPILEPSY HEART DISEASE MENTAL HEALTH DEATH FROM HEART DISEASE PRIOR TO AGE 50 SUDDEN DEATH SICKLE CELL TRAIT OR ANEMIA OSTEOPOROSIS SECTION 5 PERSONAL MEDICAL HISTORY HAVE YOU EVER HAD? Please mark an X to all those that apply. CONDITION X CONDITION X CONDITION X Measles Eczema Hepatitis A German Measles Epilepsy Hepatitis B Mumps Migraine Headaches Hepatitis C Chicken Pox Tuberculosis Hepatitis D Whooping Cough Diabetes Colitis or other Bowel Disease Scarlet Fever Cancer Hemorrhoids or any rectal disease Scarlatina Seizures Mental Illness Treatment Pneumonia Neuritis Asthma Pleurisy Neuralgia Exercise Induced Asthma Rheumatic Fever Small Pox Frequent Infections or Boils Heart Disease Gonorrhea Bladder Disease Arthritis Syphilis Anorexia Rheumatism Gallbladder Disease Bulimia Any bone or joint disease Anemia Jaundice Hives Please note any disease you have had that is not listed above: SURGICAL HISTORY: List all surgeries in the past 5 years TYPE OF SURGERY BODY PART DATE OF SURGERY Have you ever been advised to have a surgery that was not done? (Y/N) Please explain:

3 ALLERGIES HISTORY: List any allergies to: MEDICATIONS: FOOD: INSECTS: Do you have a prescription for an Epipen? (yes or no) Reaction: Reaction: Reaction: IMMUNIZATIONS HISTORY: Please mark an X to all those that apply. Immunization X Date Immunization X Date Diphtheria Tetanus Small Pox Polio Meningitis Measles (rubeola) Hepatitis Mumps or MMR INJURY HISTORY: Please mark an X to all injuries that apply. INJURY X If yes, please list body parts and dates Broken Bone Stress Fracture Sprain Strain Chronic Inflammation (i.e. tendinitis) Laceration Dislocation/Subluxation Concussion/Head Injury DIAGNOSTIC TESTING HISTORY: Please mark an X to all those that apply. X-RAYS ON: X If yes, please explain X-RAYS ON: X If yes, please explain Extremities Chest Extremities (cont.) Back Gall Bladder Teeth Stomach or colon Other A DIAGNOSTIC TEST USING: DIAGNOSTIC TEST : EKG CT Scan Echocardiogram MRI Have you ever.. Yes or No Please Explain Been disqualified for a heart problem? Had a blood or plasma transfusion? Been hospitalized for an illness? Been treated for a drug habit? Taken hormone tablets or injections? Been diagnosed with ADD/ADHD? Medications: Had a Tuberculosis (TB) skin test? Results: Date: Taken insulin or tablets for diabetes? Which Ones: Taken supplements? List what you have taken: Been diagnosed with Sickle Cell Trait/Disease? Problems you have in relation to sickle cell?

4 SECTION 6 CURRENT MEDICAL Please mark an X to all those that apply. HAVE YOU HAD IN THE PAST YEAR? X HAVE YOU HAD IN THE PAST YEAR? X Frequent or severe headaches Wake up at night short of breath Fainting spells Excessive shortness of breath with activity Unconscious spells Passed out with activity for any reason Blurred vision Ever been told you have a heart murmur Double vision Inability to keep up with peers Spots before eyes Purple lips or fingers Infected eyes Racing or skipping of heart Pain behind eyes High or low blood pressure Any vision change Recurrent stomach pains Earaches Nausea or vomiting Discharge from ears Abdominal cramping Ringing in ears Pain with urination Decrease in hearing Blood in urine Hearing problems Recurrent back pains Recurrent nose bleeds Recurrent joint pains Recurrent head colds Swelling of joints Sinus trouble Redness or heat of any joint Hay fever Tingling or weakness of hands or feet Persistent hoarseness Muscle spasms Difficulty swallowing Loss or change in sensations of hands/feet Enlarged glands Trembling in any extremity Recurrent sore throat Growth in neck or throat Recurrent sores in mouth Tiredness with no apparent reason Soreness or bleeding gums with brushing Brittleness of nails Chest pain Dryness of skin Coughed up blood Easy bruising Pain in arms Inability to stand heat Night sweats Inability to stand cold Chronic or frequent cough Change of hair texture Chronic/frequent cough w/ lying Down Any skin rash Do you experience dizziness with activity? Do you have swelling of the hands, feet or ankle? What time of day does it occur: Do you experience belching or heartburn? Does food make it better/worse: How many times a day do you urinate? Do you wear contact/glasses during competition? When were they last checked? BODY WEIGHT What is your current body weight? How much did you weight one year ago? Do you worry about you weight? How do you rate your appetite? Does your weight affect how you feel about yourself? Do you feel you have lost control over what you eat? What is the most you have ever weighed? What s the least you ve weighed in the past 5 years? Do you limit the foods you eat? Do you replace meals with supplements? Do you lose weight to meet image requirements for your sport? Do you make yourself vomit, use diuretics or laxatives to control your weight?

5 CURRENT MEDICATIONS: Please mark an X to all that apply: Accutane Advil Albuterol Amoxicillin Aspirin Atrovent Benadryl Claritin Ibuprofen Keflex Lithium Midol Minocycline Paxil Proventil Ritalin Sudafed Sulfa Drugs Tetracycline Tylenol Ventolin Xanax Zantac Zoloft Please list any medication you are taking that is not listed above: Do you use an inhaler? Do you take a prescription anti-inflammatory? What kind and why: What kind and why: WOMEN ONLY MENSTURAL HISTORY Regular Cycles? (Y/N/varies) Flow (heavy/medium/light) Pain or Cramps (Y/N) Date of last pelvic exam Date of last Pap test Any discharge from vagina? (Y/N) Do you take birth control? (Y/N) Cycle Start to Start Clots Passed (Y/N) Date of last period Itching in vaginal area? (Y/N) Results of last Pap test If yes, note color and amount If yes, what kind and how long? MEN ONLY Do you experience any discharge from penis? (Y/N) I,, confirm that, to the best of my knowledge, that all the demographic, medical and insurance information reported in this document is accurate. I understand that any incorrect, misrepresented or undisclosed information may compromise my level of medical care, delay my clearance to participate as an intercollegiate athlete at Missouri State University and/or disqualify me from participation altogether. Athletes Signature (if over 18 years of age) Date Parent/Guardian Signature (if athlete is under 18) Date _ PERMISSION TO TREAT (for athlete under the age of 18): Permission is given for the Athletic Medical and Rehabilitation Services, MSU Team Physicians and Taylor Health Center to perform such examinations, immunizations, and medical tests as are deemed necessary and to administer such medical treatment as may be advisable to. I understand that the expenses incurred for medical care beyond that which is provided within Athletic Medical and Rehabilitation Services are my responsibility. Parent/Guardian Signature Date

6 IMPORTANT INFORMATION FOR YOU TO PROVIDE PHOTOCOPY OF INSURANCE CARD please make a photocopy of the front and back of the athlete s insurance card, and bring that photocopy with you at the time of your physical. If possible, please enlarge the copy and make sure the copy is readable. If you do not have the means to do so, you can present the actual card at the time of your physical and we will make the copy for you. PRE-REGISTERING WITH MERCY HOSPITAL - We are very fortunate to have the opportunity to have our Team Physicians come to campus to see our athletes. However, in order to accommodate this, Mercy Hospital has mandated that all of our athletes pre-register with them as patients to facilitate the billing process for services both on and off campus. This must be done prior to receiving service from our team physicians or Mercy Hospital. To do so please call: (417) Inform them that you are a MSU athlete needing to register before you get your physical with either Dr. Brian Mahaffey or Dr. Landon Hough. You will need to give them your insurance information as the primary payer, and then inform them to put Missouri State University Athletics as a separate guarantor. Please keep in mind that this separate guarantor does not insure MSU will pay the balances, the situation must still fit within our policy. UPDATED: 6/05/12 Please provide any additional information you deem necessary to yours or your child s healthcare: