Upper Iowa University Athletic Training. Name: Last First Middle. Home Address: Street Address City State Zip

Similar documents
Jones Co. Jr. College Sports Medicine Medical History Questionairre

INITIAL MEDICAL PACKET

Health Services & Sports Medicine Entrance / Pre-Participation Physical Exam

AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists

Pre-participation Physical Evaluation

Celebration Lutheran School

UWSP Medical History Form

AVORS MEDICAL GROUP Antelope Valley Orthopaedic & Rehabilitation Specialists

Oxford Golden Bears Comprehensive Initial Pre-Participation Physical Evaluation

CONTENTS ALL PARTS OF THIS PACKET ARE IMPORTANT, AND IT MUST BE COMPLETED IN ITS ENTIRETY!

Durham Public Schools Assumptions of Risk/Medical Treatment Release

Edward Waters College Athletic Training General Information Form

Did you complete the Sports Ware Online required information (

TRYOUT REQUEST COVERSHEET FOR PROSPECTIVE STUDENT

Part I: Health Form. This form is to be completed by the incoming student by July 15. Name: Date of Birth:

have completed a physical exam on Print Physicians Name on. Name of Patient

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

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

Student Health Services Office 5400 Ramsey Street Fayetteville, North Carolina Phone: (910) or (910) FAX: (910)

ATHLETIC CONTRACT. I will strive to give my best to the team in every practice and every game.

PATIENT REGISTRATION

FRESHMEN/TRANSFER STUDENT CHECKLIST

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

MOUNT VERNON CITY SCHOOL DISTRICT ATHLETICS and HEALTH SERVICES

Certificate of Health Examination and Immunity

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

Southwestern Community College Extension Education Fire & Rescue Training Programs Student Medical Form

Mount Mystics MSVU Athletics & Recreation

Sudden Cardiac Death in Young Athletes

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form.

STUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410

VGCC VANCE-GRANVILLE COMMUNITY COLLEGE

Pre-participation Physical Examinations

PATIENT INFORMATION FORM (WOMEN ONLY)

PART I - ATHLETIC PARTICIPATION (To be filled in and signed by the student)

Let s Celebrate

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form.

Calumet 2017 staff/trainee/volunteer Health History & Examination Form PO Box 236, West Ossipee, NH Fax

Spring Hill College Athletic Training Department NCAA Division II Tryout

Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian:

Welcome to About Women by Women

Illinois State University. Athletic Training Education Program

PATIENT INFORMATION SCHOOL/LOCATION

Huntsville High School Swim and Dive Check List. Name:

Date of Exam: Name: Date of Birth Sex Age Grade School

THE UNIVERSITY OF ALABAMA SPORTS MEDICINE MEDICAL HISTORY

THIS FORM IS TO BE COMPLETED BY CANDIDATE.

HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.

ATHLETE REGISTRATION FORM

PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:

Student s Name Male Female Date of Birth Grade. Parent s/guardian s Name Date Phone # Family Physician Phone #

PATIENT REGISTRATION

Program or Major Code: Current address: Blazer ID: Local Address: Permanent Address

MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No

Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician

WELCOME Patient Registration Date:

Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:

HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.

Dear Student-Athlete,

MEDICAL HISTORY (To be filled in by patient)

DON T WAIT: SUBMIT YOUR HEALTH FORMS AND COMPLETE YOUR ONLINE HEALTH INSURANCE WAIVER!

WELLNESS CENTER Student Health Services (434) FAX (434)

PATIENT INFORMATION Please print clearly and complete all blanks

Medical and Dental Health History Form Getting to Know You As Our Patient

Cell Phone #: Home Phone #: ** Address (prefer your forever address):

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:

, -. /)! * )0 " # /#/# # #!!# "1 #)'!/#! /-)!2

Signature of student Date Signature of parent or guardian (if student is a minor) Date

medical questionnaire Date: Day Month Year

Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?

4. ADD/ADHD Medical Documentation Athlete is responsible for reading, completing, and providing required documentation.

Medical Questionnaire

Name of Recipient: Recipient s DOB (if known) Relationship to Recipient: (Example: mother, father, sister, brother, friend, etc)

Chiropractic Registration and History

NEW Adult Patient Information

Patient Information. Name: Last First MI. Address: Street City State Zip

This document must accompany the CAMPER MAIL-IN registration form

Patient Medical and Dental History Personal Information. Name Date

Single Married Divorced Widowed Male Female

Adult New Patient Intake. Your Health Summary

Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

S Student Date of Birth (MM/DD/YYYY) Academic School Year Graduating Class

Athlete Medical Form. Page 1 of 3 NEW RENEWAL UPDATE. Area Delegation Code Delegation Name

Last First MI. Full Mailing Address:

Florida Atlantic University Athlete Demographic

Pre-Participation Medical Questionnaire Team Canada Volleyball Centralized Training

Wynne Huang, M.D. Family Medicine

Student Health Services

STEPHEN C. SNITZER, D.D.S.,

APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC

NEW PATIENT QUESTIONNAIRE

NEW JERSEY DEPARTMENT OF EDUCATION INTRAMURAL AND INTERSCHOLASTIC ATHLETIC PRE-PARTICIPATION FORMS

Practice Member Profile

New Patient Information

MARINA HS SPORTS PHYSICALS

Date: New Patient Form First Visit Date:

Medical Health Information (continued):

Transcription:

Upper Iowa University Athletic Training MEDICAL HISTORY Personal Data Name: Last First Middle Home Address: Street Address City State Zip School Address: Street Address City State Zip Home Phone #: Cell Phone #: E-mail Address: Social Security #: Date of Birth: Gender: Fr /So /Jr /Sr/ 5 th yr: Sport(s): In Case of Emergency, Notify: Name: E-mail Address: Last First Home Address: Relationship: Street Address City State Zip Home Phone #: Work Phone #: Cell Phone #: Current Medications/Supplements/Birth control: List prescription or over-the-counter and if there are more than three list on a separate sheet of paper and notify your Certified Athletic Trainer. List: Name Dosage Prescribing doctor Reason for use 1. 2. 3. Immunization: Most recent. Tetanus: HBV: MMR: : Family History: Has anyone in your immediate family had? If marked yes explanation is required with dates: Sudden Death (Before 50) Heart Disease/Heart Attack Heart Murmur Abnormal Heart Rate/Palpitation High Blood Pressure/Hypertension Diabetes Marfan Syndrome Epilepsy Blood Disorder 1

Personal Medical History: Have you ever had/currently have any of the following conditions? ADD/ADHD Anemia/Low Blood Counts Appendicitis Asthma/Breathing Problems* Chicken Pox Constipation/Diarrhea/Hemorrhoids Eating Disorder (anorexia, bulimia) Emotional Disturbance (Depression / Anxiety) Epilepsy/Seizure Disorder Hearing Impairment/Loss Hernia Hepatitis/Liver Problems/Jaundice Kidney Disease/Stones/Injury Migraine/Headaches Missed a game due to illness Menstrual Irregularities Mononucleosis Pins/Staples/Wires/Screws in body Pneumonia/Frequent Respiratory Infections Recurrent Ear Infections Sexually Transmitted Disease Sinus Infection/Nasal Polyps/Nose Fracture Spleen/Liver Injury Stomach Problems (bleeding, ulcers) Stress Fracture Thyroid Disorder Tuberculosis Tumor/Growth/Cyst Urinary Problems (blood, recurrent infections) Human Immunodeficiency Virus (HIV) * If you have an inhaler for Asthma/Breathing problems or any emergency medications; bring an extra to your Certified Athletic Trainer prior to the start of team activities. Internal/Surgical History: Were you born WITHOUT a complete set of organs (eyes, kidneys, ovaries/testes, etc )? Have you ever had to repair / remove any organ (hernia, tonsils, appendix, spleen, etc )? Allergies: Aspirin Anti-Inflammatories Codeine Hay Fever Insect Stings/Bites Latex Penicillin Sulfa Any Foods If you have an epi-pen or any emergency medications for your allergies; bring extra to your Certified Athletic Trainer prior to the start of team activities. Cardiac History: Have you ever had/currently have any of the following conditions? High blood pressure/hypertension Irregular heart beat/palpitations Felt dizzy/light-headed/passed out during or after exercise? Have seen a cardiologist Rheumatic heart disease Had an echocardiogram/ekg Had a stress test? Chest pain/tightness/discomfort with Heart Murmur exercise? Easily fatigued Exertional shortness of breath 2

Heat Illness History: Have you ever? Become dehydrated Had heat cramps Had heat exhaustion Had heat stroke Received IV fluids Had an intolerance to heat **Vision History: Have you ever/do you currently: Had an eye injury Wear glasses/contacts/protective eyewear Have you had an eye exam in the last year Diabetes: Have you ever/do you currently: Have diabetes Have complications with your diabetes Do you have an insulin pump Dental History: Have you ever/do you currently: Had a tooth knocked out/loose/chipped Wear a dental appliance Wear a protection device Sickle Cell Disease: Have you ever/do you currently: Have sickle cell disease Have sickle cell trait Have you been tested for sickle cell trait Have a family history of sickle cell **If you have contacts or glasses please bring a copy of your prescription to your Certified Athletic Trainer. If you wear contacts please bring an extra pair to your ATC so we have them in case one is lost, destroyed, and for road trips. Please describe below any further general medical information which is knowledgeable to you and has not been requested. Orthopedic History Head Injury: Have you ever had/currently have: Concussion Knocked out/unconscious Recurrent headaches/migraines Fracture X-ray/CT/MRI Cervical Spine/Neck: Have you ever had/currently have: Disc injury Pinched nerve/stinger in arms or legs in arms or legs 3

Shoulder/Upper Arm: Have you ever had/currently have: /Subluxation Shoulder Separation Elbow/Forearm: Have you ever had/currently have: Wrist/Hand/Finger: Have you ever had/currently have: Spine/Low Back: Have you ever had/currently have: Nerve/Disc Injury in leg Pain in leg in leg Ribs/Chest: Have you ever had/currently have: 4

Hip/Groin: Have you ever had/currently have: Thigh: Have you ever had/currently have: Fracture Knee: Have you ever had/currently have: /Subluxation Torn cartilage/meniscal injury Swelling Locking/Giving away Ankle/Lower Leg: Have you ever had/currently have: Instability Stress Fracture/Shin Splints Foot/Toe: Have you ever had/currently have: 5

Please describe below any further medical information which is knowledgeable to you and has not been requested. The undersigned, hereby: I, the undersigned, hereby acknowledge, affirm, and represent that all statements are true and accurate to the best of my knowledge; and that no answers or information have been withheld. I fully understand that UIU, its agents, servants, trustees, and employees disclaim liability for any previous medical condition, whether included or omitted on this form, and will not be held liable for any injuries and/or illnesses. I further understand that having passed the physician examination does not necessarily mean that I am physically qualified to engage in athletics, but only that the examiner did not find any medical reason to disqualify me. Student-Athlete Printed Name Student-Athlete Signature Date If under 18, a parent/guardian must sign as well. Parent / Guardian Printed Name Parent / Guardian Signature Date I acknowledge and understand by typing my name in the signature blanks, I am submitting my signature and have read and understand the information on this form. 6

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback