VARSITY AND CLUB SPORTS PACKET If you are planning to participate or feel that there is a possibility that you might participate in a Varsity or Club Sports you must submit all the documents listed below. Students who do not submit all of their required pre entrance health forms and all of the required Pre participation forms will not be allow to participate in team practice. All students are encouraged to submit these forms. ALL POTENTIAL ATHLETES: Expanded History Form for Varsity and Club Sports Participation Student must complete and sign the questionnaire Medical Clearance for Varsity and Club Sports Participation Provider must complete and sign the follow up questions and clearance status Physical Exam must be completed after 2/15/17 for fall semester and 7/15/17 for spring semester Sickle Cell Screening Form WHEN APPLICABLE: NCAA Medical Exemption Form to support the diagnosis of Attention Deficit Hyper Activity Disorder (ADHD) and treatment with banned stimulant medications. NCAA Medical Exemption Form for use of Beta 2 agonists
EXPANDED HISTORY FORM REQUIRED FOR VARSITY AND CLUB SPORTS PARTICIPATION STUDENT NAME DATE OF BIRTH GENERAL QUESTIONS YES NO 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? Asthma Anemia Diabetes Infections Other: 3. Have you ever spent the night in the hospital? 4. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU YES NO 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 7. Does your heart ever race or skip beats (irregular beats) during exercise? 8. Has a doctor ever told you that you have any heart problems? If so, check all that apply: High Blood Pressure Heart murmur High Cholesterol Heart infection Kawasaki Disease Other: 9. Has a doctor ever ordered a test for your heart? (example: ECG/EKG, echocardiogram) 10. Do you get lightheaded or feel more short of breath than expected during exercise? 11. Have you ever had an unexplained seizure? 12. Do you get more tired or short of breath more quickly than your friends during exercise? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY YES NO 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50(including drowning, unexplained car accident, or sudden infant death syndrome)? 14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, short QT syndrome, Brugada syndrome or Catecholaminergic polymorphic ventricular tachycardia? 15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? BONE AND JOINT QUESTIONS YES NO 17. Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice or game? 18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x rays, MRI, CT scan, injections, therapy, brace, cast or crutches? 20. Have you ever had a stress fracture? 21. Do you regularly use a brace, orthotics or other assistive device? 22. Have you ever been told that you have or have you had an x ray for neck instability? 23. Do you have a bone, muscle or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease? MEDICAL QUESTIONS YES NO 26. Do you cough, wheeze or have difficulty breathing during or after exercise? 27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, your spleen, or any other organs? 30. Have you had infectious mononucleosis within the last month? 31. Do you have any rashes, pressure sores, or other skin problems? 32. Have you had a herpes or MRSA skin infection? 33. Have you ever had a head injury or concussion? 34. Have you ever had a hit or blow to the head that caused confusion, prolong headache or memory problems? 35. Do you have a history of seizure disorder? 36. Do you have headaches with exercise? 37. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? 38. Have you ever been unable to move your arms or legs after being hit or falling? 39. Have you ever become ill while exercising in the heat? 40. Do you get frequent muscle cramps when exercising? 41. Do you or someone in your family have sickle cell trait or disease? 42. Have you had any problems with your eyes or vision? 43. Have you had any eye injuries? 44. Do you wear glasses or contact lenses? 45. Do you wear protective eyewear, such as goggles or a face shield? 46. Do you worry about your weight? 47. Are you trying to or has anyone recommended that you gain or lose weight? 48. Are you on a special diet or do you avoid certain types of food? 49. Have you ever had an eating disorder? Medicines and Allergies: Please list all of the prescription and over the counter medicines and supplements (herbal and nutritional) that you are currently taking: Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects I hereby state that, to the best of my knowledge, my answers to the above questions are correct. Signature of Athlete: Signature of Parent\Guardian: Date:
MEDICAL CLEARANCE FOR VARSITY AND CLUB SPORTS NAME DATE OF BIRTH EXAMINER: Please complete the following: Yes No 1. Do you feel stressed out or under a lot of pressure? 2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days? 3. Do you feel safe? 4. Have you ever tried cigarette smoking, even one or two puffs? Do you currently smoke? 5. During the past 30 days, have you had at least one drink of alcohol? Number of drinks this past week 6. Have you ever used drugs (marijuana, cocaine, heroin, LSD, amphetamines, etc.)? Last use 7. Have you ever taken any over the counter medications to help you gain or lose weight or improve your performance? 8. Have you ever been treated for ADD or ADHD. If yes, list current medication and dosage. Students who have positive answers to risk factors for CV Disease or who have physical findings suggestive of CV Disease documented on the Mandatory Physical Exam Form, must have an ECG and further cardiology evaluation as clinically indicated. On this date I have reviewed the medical and expanded history and examined this student. On this basis, the student is: CLEARED For all sports with no restrictions NOT CLEARED Further Evaluation Pending Cleared with restrictions n Other; please describe: Personal Protective Gear Required: Limited Contact Sports Noncontact Sports only HEALTH CARE PROVIDER SIGNATURE REQUIRED EXAMINER S SIGNATURE DATE NAME ADDRESS PHONE
Due Date: July 1, 2017-Fall Entrants December 1, 2017-Spring Entrants Mandatory Physical Exam The date of the last physical exam must have been AFTER 08/15/2016 for Fall Entrants and 01/15/2017 for Spring Entrants Please note: Physical for Varsity and Club Athletes must be after 02/15/2017 for Fall Entrants and 07/15/2017 for Spring Entrants Date of Exam STUDENT NAME Date of Birth Height: ft in Weight lbs. BP: / Pulse Please answer all questions and provide all physical data requested on the form. Cardiovascular History YES NO Prior exertional chest pain Prior exertional syncope/near syncope Excessive, unexplained shortness of breath or fatigue with exercise Prior history of heart murmur or elevated blood pressure Family history of premature death from cardiovascular disease in a relative younger than 50 Occurrence in family of hypertrophic cardiomyopathy or dilated cardiomyopathy, long QT or Marfan s syndrome Prior Restriction for Sports Prior Cardiovascular Testing Physical Exam Record Result Describe Abnormality Heart/Vascular system Precordial Auscultation in both supine and standing positions to identify murmurs consistent with dynamic left ventricular outflow obstruction Assessment of femoral artery pulses to exclude coarctation of the aorta Presence of physical stigmata of Marfan s Syndrome Skin HEENT Lungs/Chest Abdomen (rectal if indicated) Musculoskeletal Neurological Other Significant Findings Lab work recommended Hgb/Hct Cholesterol HDL LDL Is student being treated for a chronic/ongoing medical or orthopedic condition or a serious illness? No Yes, IF YES, PLEASE PROVIDE A SEPARATE LETTER WITH PERTINENT HISTORY AND ONGOING TREATMENT PLAN TO ASSIST US IN PROVIDING CONTINUITY OF CARE. ALLERGIES (medications, insect venom, foods) Type of reaction Does the student have an Epi Pen? Yes No CURRENT MEDICATIONS (include prescription, non prescription and supplements): Do you have any dietary recommendations? No Yes. Please specify: Please note any additional recommendations regarding this student: Health care provider: Address: Phone: Fax: Provider s signature: Date: Health Care Provider Signature Required
Mount Holyoke College Sickle Cell Trait Form for Varsity and Club Sports About Sickle Cell Trait Sickle Cell Trait is not a disease. Sickle Cell Trait is an inherited condition affecting the oxygen-carrying substance, hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like a disease. Sickle Cell Trait is a common condition (> three million Americans.) Although Sickle Cell Trait occurs most commonly in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this condition. Those with Sickle Cell Trait usually have no symptoms or any significant health problems. However, sometimes during very intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in those with Sickle Cell Trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden collapse and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3 continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning training. Extreme heat and dehydration increase the risks. More information and resources regarding Sickle Cell Trait and the NCAA s recommendation for Sickle Cell Trait testing can be found at the NCAA website resource pages regarding Sickle Cell Trait, accessible at: http://www.ncaa.org/health-and-safety/medical-conditions/sickle-cell-trait http://www.ssilearn.org/ Sickle Cell Trait Testing The NCAA recommends that all student-athletes have knowledge of their Sickle Cell Trait status. Student-athletes must complete one of the following: 1. Show proof a prior test results. OR 2. Have a blood test to check for Sickle Cell Trait OR 3. Sign a testing waiver declining options 1 and 2 Whichever option is chosen, it must be completed before the athlete participates in any intercollegiate athletic events, including strength and conditioning sessions, practices, competitions, etc. Athletes who are positive for the Trait will be allowed to participate in intercollegiate athletics; this does NOT prohibit you from playing. One of the following options MUST be chosen. Please select one and include ALL required documentation: Copy of athlete s newborn sickle cell testing result ATTACHED: Date: Most states require testing at birth, check with your hospital or pediatrician Copy of recent Sickle Cell screening test result ATTACHED: Date: Cost of testing is the responsibility of the athlete SICKLE CELL TESTING WAVIER: By signing this waiver, I understand and acknowledge that the NCAA recommends that all Student-Athletes have knowledge of their Sickle Cell Trait status. Additionally, I certify that I have read and fully understand the aforementioned facts and I have had the opportunity to review the NCAA website for further information about Sickle Cell Trait and Sickle Cell Trait testing. I DO NOT wish to undergo Sickle Cell Trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless, Mount Holyoke College, it officers, employees, agents and their successors and assigns from any and all costs, claims, damages or expenses, including attorney s fees, arising from any loss or personal injury that might result from my refusal to be tested. I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Athlete s Signature Athlete s Name Printed Date Parent/Guardian s Signature (if under 18 years of age) Parent/Guardian s Name Printed Sport
ADD/ADHD Medical Exception Form Dear Health Care Provider, On August 1, 2009, the NCAA enacted legislation affecting student athletes diagnosed with ADD/ADHD who are receiving treatment in the form of prescription stimulants that may be on the banned substance list. This legislation requires these student athletes to request documentation from their health care provider supporting the diagnosis of ADD/ADHD and subsequent use of prescription stimulants for treatment. The documentation will be kept on file within the Athletics Department and will need to be updated by the student athlete s health care provider as the student athlete s course of treatment changes. More information regarding this topic can be found on the NCAA s Health and Safety web page. Provider, please fill out the following information: Student Athlete Name: Date of Birth: Date of Clinical Evaluation: Diagnosis: Date of Diagnosis: Date of Most Recent Follow Up: Medication & Dosage: Please include all of the following information in your documentation: Provide summary of comprehensive clinical evaluation (referencing DSM V criteria) and attach supporting documentation Provide ADHD Rating Scale(s) (e.g., CAARS, Connors, ASRS) scores and report summary, and attach supporting documentation Provide blood pressure & pulse readings and comments Brief summary explaining that alternative non banned medications have been considered and reasoning why they were not utilized Please provide the following additional information if available: Reporting of ADD/ADHD symptoms by other significant individuals and attach supporting documentation Psychological testing results Physical exam date and results Laboratory/testing results Summary of previous ADHD diagnosis Follow Up:
The student athlete will have a follow up with me in (circle one): 3 months 6 months 12 months Other Additional Comments: Physician Name (Printed): Specialty: Office Address: Office Phone #: Office Fax #: Physician s Signature: Date:
MEDICAL EXCEPTION DOCUMENTATION FOR USE OF BANNED MEDICATIONS Dear Health Care Provider, The NCAA requires Mount Holyoke College to maintain documentation supporting the student athlete s use of medications that may be or contain a banned substance, such as with beta 2 agonists. This documentation must be maintained in the student athlete s medical record on campus. More information regarding this topic can be found on the NCAA s Health and Safety web page. Please Fill Out the Following Information: Student Athlete Name: Date of Birth: Date of Clinical Evaluation: Diagnosis: Date of Diagnosis: Date of Most Recent Follow Up: Medication & Dosage: Please include the following information from the prescribing health care provider: A letter or copies of medical notes that documents the diagnosis and how it was reached, including appropriate verification of the diagnosis Detailed medical history of the student athlete that demonstrates the need for treatment with a potentially banned medication, and that other non banned alternative medications were considered Follow Up: The student athlete will have a follow up with me in (circle one): 3 mos / 6 mos / 12 mos / Other Additional Comments: Physician Name (Printed): Specialty: Office Address: Office Phone #: Office Fax #: Physician s Signature: Date: