NEW ATHLETE PHYSICAL FORM

Transcription

1 NEW ATHLETE PHYSICAL FORM Student-Athlete Name: Sport: Student-Athlete Medical History Questionnaire Pre-Participation Information Name: Sport: Classification: Date of Birth: Social Security #: Cell Phone #: This is a screening evaluation and is not meant to, nor should it, take the place of a standard complete physical examination. Pre-Participation Medical History The following questions are to be answered yes or no. Please check the appropriate box. Comment on all YES answers. Have you ever: Y N Comments: Been hospitalized or had any surgery? ( ) ( ) Have you or anyone in your immediate family ever had: Diabetes (high blood sugar)? ( ) ( ) Sudden death (age less than 50)? ( ) ( ) High blood pressure? ( ) ( ) High Cholesterol? ( ) ( ) Heart Attack (age less than 50)? ( ) ( ) Asthma? ( ) ( ) Have you ever had or do you now have: Chest pain with or after exercise? ( ) ( ) Dizziness with or after exercise? ( ) ( ) Passing out with or after exercise? ( ) ( ) Wheezing/cough with exercise? ( ) ( ) Weakness/fatigue with or after exercise? ( ) ( ) Heat exhaustion or intolerance? ( ) ( ) Racing of the heart/irregular rhythm? ( ) ( ) Have you had or do you now have: Hearing loss or perforated eardrum? ( ) ( ) Headaches or migraines? ( ) ( ) Dental plate or orthodontic work? ( ) ( ) Impaired vision, wear glasses/contacts? ( ) ( ) Unequal pupils? If yes, R or L larger? ( ) ( ) Anemia? ( ) ( ) High blood pressure? ( ) ( ) Rheumatic heart fever or heart murmur? ( ) ( ) Infections (Staph/MRSA)? ( ) ( ) Frequent anxiety, depression, insomnia? ( ) ( ) Hernia? ( ) ( ) Loss of function or absence of paired organ? ( ) ( ) Weight problem (or recent weight gain/loss)? ( ) ( ) Do you have the Sickle Cell Trait or been diagnosed with Sickle Cell Anemia? ( ) ( ) Are you currently taking medication for ADD/ADHD? ( ) ( ) Are you currently taking medication for Asthma? ( ) ( )

2 NEW ATHLETE PHYSICAL FORM Student-Athlete Name: Sport: List any current supplements or vitamins (include protein, weight gainer, etc.): List any allergies to medicine, food, and/or bees: PLEASE ANSWER THE FOLLOWING QUESTIONS IN AS MUCH DETAIL AS POSSIBLE: 1. Have you ever had a Head injury involving any of the symptoms listed? If YES, give date of injury, sport, and time lost from play. Y N Y N a. Loss of memory ( ) ( ) b. Disorientation ( ) ( ) c. Dizziness ( ) ( ) d. Mental Confusion ( ) ( ) e. Loss of consciousness ( ) ( ) f. Blurry/ double vision ( ) ( ) g. Loss of vision ( ) ( ) h. Nausea/Vomiting ( ) ( ) i. Headaches ( ) ( ) j. Skull fractures ( ) ( ) Date Injury Sport Time Lost ( Y )( N ) Have you ever had a Neck injury? If YES, then: 3. ( Y )( N )Have you ever had a Back injury/pain? If YES, then:6-4. ( Y )( N )Have you ever had a Shoulder injury? If YES, then: ( ) Right ( ) Left ** Did you wear a Brace? 5. ( Y )( N )Have you ever had a Elbow injury? If YES, then: ( ) Right ( ) Left ** Did you wear a Brace? 6. ( Y )( N )Have you ever had a Wrist/Hand/Finger injury? If YES, then: ( ) Right ( ) Left **Did you wear a Brace?

3 NEW ATHLETE PHYSICAL FORM Student-Athlete Name: Sport: 7. ( Y )( N )Have you ever had a Knee injury? If YES, then: ( ) Right ( ) Left ** Did you wear a Brace? 8. ( Y )( N )Have you ever injured/sprained your Ankle? If YES, then: ( ) Right ( ) Left ** Did you wear a Brace? 9. ( Y )( N )Have you ever had a Stress Fracture? If YES, then: ( ) Right ( ) Left ** Did you wear a Brace? 10. Have you ever been treated for a mental condition? If YES, specify when, where, and nature of condition:

4 NEW ATHLETE PHYSICAL FORM Student-Athlete Name: Sport: Women Only: Female Health History Name: Date: Comments Are your menstrual cycles regular? Yes No Age of onset: Date of last period: # of days between periods: # of periods in last 12 months: Duration of period: Have you ever gone for more than two months without a period? YES NO Is the flow heavy? YES NO Is heavy bleeding ever a problem? YES NO Ever have bleeding between periods (spotting)? YES NO Ever experience unusual discharge? YES NO Are cramps a frequent problem? YES NO Any past pregnancies/ births? YES NO Are you on birth control pills? YES NO Do you use another form of contraceptive? YES NO Do you perform breast self-exams? YES NO Do you experience frequent urinary tract infections? YES NO Have you ever had a blood clot in your veins? YES NO Have you ever had a gynecological exam? YES NO Date of last examination: Have you ever had a PAP smear? YES NO Date of last PAP smear: Have you ever had an abnormal PAP smear? YES NO Date of abnormal PAP: Have you ever been treated for anemia? YES NO Have you ever been treated for an eating disorder? YES NO Are you happy with your current weight? YES NO What would you like to weigh? Do you ever feel pressure to lose weight? YES NO By whom (coaches, parents, peers, etc.)? YES NO Have you ever tried to control weight by: Diet Pill? YES NO Diuretics? YES NO Fasting? YES NO Laxatives? YES NO Vomiting? YES NO Would you like information about healthy weight loss? YES NO

5 NEW ATHLETE PHYSICAL FORM Student-Athlete Name: Sport: Pre-Participation Physical Screening Evaluation Name: Gender: M F Age: D.O.B.: Height: Weight: Blood Pressure: / Pulse: Left Eye: / Right Eye: / Corrected: yes / no Pupil: Equal Unequal: Normal Abnormal Comments MUSCULOSKELETAL: Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot Hamstring Flexibility Reflexes INTERNAL: Heart Lungs Lymphatic Thyroid Skin Abdominal Participation Status: Full Unlimited Participation in Intercollegiate Athletics Conditionally Cleared with the Following Exceptions (explain): Participation withheld until (explain): Disqualifications (explain): General Medical Physician s Signature: Examining Physician Orthopedic Physician s Signature: Examining Physician Reviewed by: Certified Athletic Trainer Date Date Date

6 Faulkner University Athletic Participation Consent Form This form must contain the signatures of the student-athlete and his/her parent(s)/guardian(s), regardless of the athlete s age. The policies and guidelines in this packet will remain in effect for a student-athlete s entire athletic participation at Faulkner University unless there is a change in Faulkner policy or procedure. If changes occur, student-athlete will be required to reaffirm acceptance of policies. As a student-athlete at Faulkner University (or parent/guardian of student athlete named below), I/we hereby acknowledge that the guidelines, requirements, programs and policies contained within the Faulkner University Student Athletic Information Packet will govern the student athlete s participation in Faulkner University s Athletic program for the entire time period of the student s enrollment and athletic participation. Should any guidelines, requirements or policies change during the course of my athletic participation, I/we understand that I/we will be required to agree to such amendments in writing. By signing this form, I/we hereby acknowledge that I/we have received a copy of the Faulkner University Student Athletic Information Packet and that I/we have read and understand the following warnings and guidelines that are contained within this packet: Section 1: Assumption of Risk and Injury, Medical Eligibility and Treatment Procedures Section 2: Athletic Insurance Program & 60-Day Insurance Billing Notification Requirement Section 3: Concussion Information for Student-Athletes, Parents, and Coaches Section 4: Consent for Release of Information Parent(s)/Guardian(s) of Minors: If the undersigned student-athlete has not yet reached the age of majority in his/her home state as the parent(s)/guardian(s) of said student athlete, I/we do hereby give consent for his/her treatment at the Faulkner University Athletic Training facilities, Pro Impact Physical Therapy and Sports Performance facilities, and medical providers (diagnostics, MD s, surgeons, etc.). This consent includes hospitalization and related treatment. Participant name [print] Participant signature Date Parent/Guardian #1 name [print] Parent/Guardian #1 signature Date Parent/Guardian #2 name [print] Parent/Guardian #2 signature Date [If you share legal custody of the participant with anyone else, that person s signature is also required. For the sake of convenience, the other parent/guardian may download a copy of the Parent Signature Pack, print and sign the pages requiring a signature and submit them separately to the University via mail, fax ( ) or by attaching to an and sending same to athletictrainers@faulkner.edu. (For all such signature pages that are submitted separately, please be sure to print the name of the participant.)] Effective Date 7/19/2016 Faulkner University Student Athlete Information Packet Page 2 of 19

7 ProImpact Patient Authorization Form Patient Name: Date of Birth: RELEASE OF INFORMATION & CONSENT FOR TREATMENT All information provided herein is true and correct. I am aware of my diagnosis and wish to receive treatment at this Pro Impact Physical Therapy & Sports Medicine clinic. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand that this care can include an evaluation, testing and treatment. No guarantees have been made to me about the outcome of this care. I give permission to Pro Impact Physical Therapy & Sports Performance and its subsidiaries and affiliates to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, employer, school, related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment and/or payment for services provided. I authorize Pro Impact Physical Therapy & Sports Performance and/or its subsidiaries and affiliates to obtain medical records and/or professional information from my physician or other medical professional as it relates to my treatment. I consent for medical photographs to be made of me (or my child or person for whom I am a legal guardian). I understand that the information may be used in my medical record. By consenting to these medical photographs I understand that I will not receive payment from any party (Pro Impact nor patient). Refusal to consent to photographs will in no way affect the medical care I will receive. The signature below certifies that I have read and understand the above information. ASSIGNMENT OF BENEFITS Initial: I authorize payment directly to Pro Impact Physical Therapy & Sports Performance, its subsidiaries and/or affiliates for services and to bill and release payment directly to Pro Impact Physical Therapy & Sports Performance, its subsidiaries and/or affiliates for any physical therapy, occupational therapy, speech-language pathology, rehabilitation, orthotic or prosthetic services provided. This is a direct assignment of my rights assistive device benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original. NOTICE OF PRIVACY PRACTICES (HIPAA ACKNOWLEDGEMENT/CONSENT) Initial: I hereby acknowledge that I have received a copy of The Notice of Privacy Practices for Pro Impact Physical Therapy & Sports Performance, its subsidiaries and /or affiliates. In addition, I hereby consent to the use and disclosure of my personal health information for the purposes of treatment, payment, and health care operation. Initial: Patient or Guardian Signature: Date: Effective Date 7/19/2016 Faulkner University Student Athlete Information Packet Page 3 of 19

8 ProImpact Payment Guarantee Form Patient Name: Date of Birth: PAYMENT GUARANTEE I agree to pay Pro Impact Physical Therapy & Sports Performance, its subsidiaries and/or affiliates for the services provided to me or the party named above. If any law, such as workers compensation, or an insurance contract prohibit payment for these services I will cooperate and assist in the provision of information and authorizations, released, or any other type of information necessary to allow for speedy collection from my third-party payer. Where the law or an insurance contract does not prohibit payment by me, I acknowledge responsibility for any and all account balances. The Benefit Verification form is only an explanation of coverage obtained from my insurance company and it is not a guarantee of coverage. If the information provided by my insurance company is not accurate or the insurance company changes its coverage, I will be responsible for payment of all services. If arbitrary determination of a participating insurance company indicates that a treatment or procedure is not medically necessary, the patient or patients guarantor will be responsible for the remaining balance. However, it is ultimately the responsibility of the patient or patient s guarantor to know and understand their benefits prior to starting physical therapy. FINANCIAL AGREEMENT: I fully understand that I am responsible for any and all charges associated with my account and that if I fail to pay any amount due, I will also be responsible for court costs, attorney fees, and collection fees of up to 33% of the amount due, incurred in the collection of any balance due. I give permission to Pro Impact and any of Pro Impact's vendors, which include collection agencies, attorneys and billers, to contact me on the cell phone numbers I have provided on matters related to my account. I understand that an automated dialer may be used to contact me by these parties and agree to allow them to do so. I further understand that this agreement is binding regardless of any legal transaction currently in progress or initiated during or after the course of my treatments unless agreed to in writing by myself and a representative of Pro Impact Physical Therapy & Sports Performance and/or its affiliates or subsidiaries. I understand that three statements will be generated in the course of an outstanding balance. After which, a final notice prior to collections will be mailed. Payment in full is expected on outstanding balances. If a payment plan is absolutely necessary, the terms and conditions will be determined by Pro Impact Physical Therapy and Sports Performance owner, not upon the financial plan determined by the client. I further understand and agree that, in addition to all amounts owed for services, which I will be responsible for all costs of collection including, but not limited to, attorney s fees, court cost, filing fees, and any other costs associated with or related to collection efforts instituted by Pro Impact Physical Therapy. Initial: Patient or Guardian Signature: Date: Effective Date 7/19/2016 Faulkner University Student Athlete Information Packet Page 4 of 19

9 Player Information Sheet Full Name: Preferred Name: Student ID #: Social Security #: Date of Birth: Faulkner address: Live On Campus - Dorm & Room #: Live Off Campus - Local Address: Permanent Home Address: City, State, Zip Code: Cell Phone #: Home Phone #: Classification on Field: Freshman Sophomore Junior Senior Father s Name: _ Use as Emergency Contact? Yes No Cell Phone #: Home Phone #: Work Phone #: Father s Address: City, State, Zip Code: Father s address: Mother s Name: _ Use as Emergency Contact? Yes No Cell Phone #: Home Phone #: Work Phone #: Mother s Address: City, State, Zip Code: Mother s Address: Other Emergency Contact Name: Relationship to Student-Athlete: Home Address: City, State, Zip Code: Cell Phone #: Alternate Phone #: Effective Date 7/19/2016 Faulkner University Student Athlete Information Packet Page 5 of 19

10 Primary Insurance Information Sheet Please have the primary insurance holder fill out the following information and return it to the Faulkner University Athletic Training Department along with a front and back copy of the primary insurance card. Name of Student Athlete: Sport(s): Primary Insurance Company Name: Phone #: Address: _ Group Number (if applicable): Policy Number (if applicable): (Note: If insurance is through military association, policy number is the primary member s social security number.) Please indicate if this coverage is provided by: Medicaid/State CHIP TriCare Primary Insurance Holder s Full Name: Address: Date of Birth: Social Security #: Home Phone #: Cell Phone # _ Place of Employment*: (*Note: Only required if insurance is provided by place of employment.) Primary Insurance Holder s address: I certify that, to the best of my knowledge, the information that I have provided is complete and correct. I will promptly inform Faulkner University Athletic Training Department of any changes in insurance or demographic information. If at any time my primary insurance coverage changes, I understand that I must notify the Athletic Training Department prior to the date of change. Faulkner University will not be responsible for any medical bills resulting from the lapse or cancellation of a student athlete s primary insurance coverage. Student Athlete Signature: Date: Primary Insurance Holder s Signature: Date: ALL information provided will be stored in private files in the Faulkner University Athletic Training Department and will only be disclosed if required by insurance company to file a claim. Effective Date 7/19/2016 Faulkner University Student Athlete Information Packet Page 6 of 19