TO:



[pic][pic]

Athletic Training/Sports Medicine * 125 Route 340 * Sparkill, New York 10976

TO: ALL TRANSFER and NEW STUDENT-ATHLETES

FROM: LORI RAHAIM, MEd, ATC/L

HEAD ATHLETIC TRAINER

DATE: JUNE 15, 2017

RE: ATHLETE PHYSICALS AND PRE-PARTICIPATION SCREENING EXAMS

*************************************************************************************************

The Athletic Training/Sports Medicine Staff at St. Thomas Aquinas College would like to welcome you to our athletic program; we are glad you have chosen to join us. I am the Head Athletic Trainer for STAC and I hope you are enjoying a safe and relaxing summer. In preparation for the 2017-2018 seasons, we need your help to start your sports medicine file. Enclosed you will find:

1. This letter with the date and time for your pre-participation screening exam conducted on campus by our team physicians. Please note that as a TRANSFER or NEW student-athlete, you MUST first have a COMPLETE physical with, and be cleared by, your own personal physician. They must complete and sign the green page (no substitute doctor forms please) of the Student-Athlete Sports Medicine Record.

2. A summary explaining how we handle athletic injuries and related medical expenses. Please make sure you and your parents/guardians carefully read these pages.

3. The medical history, insurance information, consent to treat, and assumption of risk forms. PLEASE READ THE INSTRUCTIONS ON ALL PARTS OF THESE FORMS. Be as complete and accurate as possible. It is very important that the athlete is familiar with the information on these forms because if we have any questions, we will be asking the athlete on the date of the pre-participation screening exams. These forms must all be completed, signed, and on file in this office before participating with any STAC athletic team.

The pre-participation screening exam date for ALL new student-athletes is listed below and is MANDATORY. Please take a minute to make a note of the date and time of this screening. We will meet in the gymnasium. Please be on time and don't forget to have your COMPLETE physical FIRST with your own personal physician BEFORE coming to this pre-participation screening exam.

Date: Monday, July 24th - from 8am until 3pm - you must arrive NO LATER than 9am

ALL new STAC student-athletes MUST attend this special screening date, this includes transfer students. You will be examined by our team physicians, meet with me individually to review your medical history, and meet with me as a group to learn more about what the training room can do for you as well as our policies and procedures for an injury, insurance, rehabilitation, drug/alcohol/tobacco violations, and our expectations for you as a student-athlete. In addition to your pre-participation screening, you will be introduced to other athletic department members and spend time with the Director of NCAA Compliance to review your compliance requirements and complete all of your NCAA paperwork. This will be a busy and informative day that you can't afford to miss.

Please be sure that you are available for this special pre-participation screening exam and plan to wear a t-shirt and shorts. The exams will consist of four parts. The FIRST part will be the medical exam - examining height, weight, pulse, blood pressure, body fat percentage, and determining your level of medical fitness. The SECOND part will be the orthopaedic exam - examining posture, joint stability, muscle strength, etc and determining your ability to sustain the physical demands of your particular sport(s). The THIRD part will be taking a NCAA-mandated concussion baseline test. The FOURTH part will be reviewing your completed physical with a member of the Athletic Training/Sports Medicine Staff. If there are no further tests/appointments required by our team physicians, then you will be cleared to participate with your team. If there are further tests to be done, appointments to be made, or other doctors to see before you are cleared, then you will not be cleared until these appointments are taken care of and I receive the appropriate paperwork clearing you. I will help you arrange any necessary appointments. There is no charge for this pre-participation screening exam; however, if you miss this screening, then you will be required to complete it at your own expense with our team physicians. Additionally, the athletic department is not responsible for any medical expenses incurred by the result of further medical testing, procedures, or doctor visits needed when underlying or pre-existing conditions are found during the exam.

If you have any significant injuries, which we will need to look at (ACL reconstruction, recurrent shoulder dislocations, back injuries, etc...) please let me know as soon as possible so that we can request medical records, talk with your physician, etc before you arrive. Your early response to this request will make your trip through this exam much easier.

A policy, which will be enforced, is that jewelry of any kind will not be allowed to be worn during practices or competitions. This policy has been created in an attempt to provide a safer environment for participation. Any injury resulting from a violation of this policy may not be covered by STAC.

I also want to remind you that since you are attending an NCAA member institution that you will be subject to NCAA drug testing policies. The NCAA's position on dietary supplements is of particular concern. Some nutritional supplements, as well as over-the-counter and prescription medications, and illegal drugs may contain substances banned by the NCAA. A positive drug test will result in the loss of institutional and/or NCAA eligibility. For more specific information, please refer to the banned list of substances on the NCAA Sports Sciences website at sports and the Dietary Supplement Resource Exchange information on the National Center for Drug Free Sport website at . We will cover the St. Thomas Aquinas College Drug/Alcohol/Tobacco Policy and Testing Procedures during your visit.

ATTENTION: ALL STUDENT-ATHLETES WITH ADHD – NCAA POLICY

Any student-athlete diagnosed with ADHD (as a child or as an adult) and taking medications (which often contain NCAA banned stimulants) MUST now supply our office with ALL mandatory documentation (as required by the NCAA) prior to any participation with STAC athletics to protect you in the event of a positive drug test. MEDICAL EXCEPTIONS will only be granted by the NCAA if ALL mandatory documentation is on file with this office PRIOR to your collegiate participation and PRIOR to a positive drug test. THIS IS YOUR RESPONSIBILITY, so please take this policy seriously – your eligibility depends on it. If you are a student-athlete with ADHD - you MUST contact me ASAP to discuss what must be done by you in order to meet this requirement.

PLEASE NOTE: SICKLE CELL TESTING IS MANDATORY FOR

ALL TRANSFER and NEW STUDENT-ATHLETES AS PER THE NCAA.

I must get an OFFICIAL RESULT print out of the actual test --- a note from your doctor is NOT acceptable documentation as per the NCAA and you cannot participate with your team until I have the official results on file in my office ---- this is YOUR RESPONSIBILITY!!

These and other STAC Athletic Training/Sports Medicine policies and procedures will be explained to you in greater detail when you arrive for your pre-participation screening exam. Again, please be sure to complete all enclosed paperwork and bring it with you to your pre-participation screening date listed above. If you have any questions, please feel free to contact me at (845)304-3177.

Lori Rahaim, MEd,ATC/L - Head Athletic Trainer

Katherine Crawford, BS, ATC/L - Athletic Trainer Intern

Katherine Zoda, BS, ATC/L - Athletic Trainer Intern

Julie LePage, BS, ATC/L - Athletic Trainer Intern

STAC ATHLETIC TRAINING/SPORTS MEDICINE STAFF

HEAD ATHLETIC TRAINER

LORI RAHAIM, MEd, ATC/L

Rahaim, begins her 29th year as a certified athletic trainer and is entering her 20th year as the Head Athletic Trainer at STAC. She is excited to welcome three new Athletic Trainer Interns – Katie Crawford, Katherine Zoda, and Julie LePage. Managing the health and safety of 300+ student-athletes is her primary concern. Lori is a native Vermonter who received her athletic training degree through the University of Vermont. She began her athletic training career at STAC in 1989. In 1995, she returned to Vermont to pursue her Master’s degree in secondary mathematics and technology at St. Michael’s College. Lori then spent the next seven years as Dean of Students/Teacher/Coach/Athletic Trainer at two private boarding high schools in Maryland before returning to STAC athletics in 2004. She resides in Nanuet, NY with her daughter Emerson.

ATHLETIC TRAINER INTERN

KATIE CRAWFORD, BS, ATC/L

Katie will begin her 1st year as part of the STAC athletic department in August. She will assist with the care and treatment of our student-athletes. Crawford hails from Massachusetts and is a graduate of Sacred Heart University with a degree in athletic training. Her primary responsibilities will include increasing our coverage of athletic contests and the overall treatment of our student-athletes. Katie will live on campus and take classes at STAC.

ATHLETIC TRAINER INTERN

KATHERINE ZODA, BS, ATC/L

Katherine will begin her 1st year as part of the STAC athletic department in August. She will assist with the care and treatment of our student-athletes. Zoda hails from New York and is a graduate of SUNY Stony Brook with a degree in athletic training. Her primary responsibilities will include increasing our coverage of athletic contests and the overall treatment of our student-athletes. Katherine will live on campus and take classes at STAC.

ATHLETIC TRAINER INTERN

JULIE LEPAGE, BS, ATC/L

Julie will begin her 1st year as part of the STAC athletic department in August. She will assist with the care and treatment of our student-athletes. LePage hails from California and is a graduate of Merrimack College with a degree in athletic training. Her primary responsibilities will include increasing our coverage of athletic contests and the overall treatment of our student-athletes. Julie will live on campus and take classes at STAC.

TEAM ORTHOPEDIC PHYSICIANS

OSCAR VAZQUEZ, MD

Dr. Vazquez and his orthopedic colleagues begin their 3rd year of supporting STAC athletics. They work from their local Emerson, NJ office – Active Orthopedics & Sports Medicine. There are 10 local, board-certified orthopedic surgeons at our service. These orthopedic MDs will be our first line of defense when it comes to athletic orthopedic injuries requiring further evaluation.

TEAM GENERAL PRACTITIONER

EDWARD GOLD, MD

Dr. Gold and his staff will also begin their 3rd year supporting STAC athletics. He works from his local Emerson, NJ office – Hackensack University Medical Group, Primary Care. Gold is board certified in internal medicine and his staff encompasses 12 specialty areas. Dr. Gold is our first line of defense when it comes to our general medicine needs requiring further evaluation.

OTHER IMPORTANT STAC STAFF MEMBERS

Vice President, Dean of Student Affairs – Dr. Kirk Manning

Athletic Director – Gerry Oswald

Associate Athletic Director, Sr. Women’s Administrator – Nicole Ryan

Assistant Athletic Director, Director of NCAA Compliance – Tobin Anderson

Assistant Athletic Director, Sports Information Director – Kim Lusk

Assistant Athletic Director, Director of Game Day Operations – Lorne Marcus

Assistant Athletic Director, Director of Facility Rentals – Graham Brown

Assistant Athletic Director, Director of STAC Fitness Center – Jonathan Garvey

Assistant Athletic Director, Director for Community Engagement – Matthew Capell

Director of Health Services/STAC Insurance Administrator – Eileen Mastrovito, RN

ATHLETIC TRAINING/SPORTS MEDICINE AT STAC

Athletic training is practiced by athletic trainers, nationally certified and state licensed health care professionals who collaborate with physicians to optimize the activity and participation of college student-athletes. Athletic training encompasses the prevention, diagnosis and intervention of emergency, acute and chronic medical conditions involving impairment, functional limitations and disabilities.

INJURY/ILLNESS SUSTAINED BY STUDENT-ATHLETE

EVERY injury or illness (including those in and out of season) MUST be reported to an athletic training/sports medicine staff member in a timely manner. It is VERY important that we have the most up-to-date medical information on all of our athletes all throughout the year so that in the event of an emergency we have all the information we need to treat each athlete properly.

EXAMPLES – if you have a DENTIST appointment, we want to know. If you are simply having your teeth cleaned, we will cross our fingers and hope for no cavities. BUT, if you are having teeth extracted/pulled/root canal – that’s a whole different story and you must return with a clearance note (see below for details of a proper clearance note).

- if you are going to an EYE DOCTOR, we want to know. Same as the dentist – if it is just for a check-up – that’s good to know. BUT, if you have sustained an eye injury or are diagnosed with pinkeye – we need to know and you must return with a clearance note.

- WOMEN – if you are going to a GYN, we want to know. If it is just for a check-up – that’s good to know. BUT, if you are experiencing a problem (ie: ovarian cysts, which can quickly go from a little abdominal pain to internal bleeding after a direct hit) – we need to know and you must return with a clearance note.

- if you are taking PAIN MEDS for ANY reason, we must know as this can be a safety issue and it could also be NCAA violation.

- if you are feeling SICK and go to the College nurse, we want to know. She may send you to a local doctor and you must return with a clearance note. We always find out about these things and we expect all student-athletes to find us before we have to go looking for you.

CLEARANCE NOTES

ANY time you go to ANY doctor for ANY reason, you MUST tell a member of the athletic training/sports medicine staff and we will advise you on whether we need a clearance note following your visit. If you are told you need to return with a clearance note – it MUST have the following:

▪ It MUST be on the doctor’s stationary/script pad

▪ It MUST state the FINAL DIAGNOSIS

▪ It MUST state the PLAN OF ACTION

▪ It MUST clearly state your RETURN STATUS for athletics – it may not say that you can return when you feel better – return decisions are NEVER left up to an athlete

If you return with a note that does not have all of the above, then it will not be accepted and you must get another clearance note. So, please pay attention to this small detail and be sure the note says EXACTLY what you and your doctor want it to say. Notes may also be FAXED to my attention at (845)398-4071 and you can check in the athletic department where the fax machine is located and bring it to us in the training room.

TREATMENT OF INJURIES/ILLNESSES

EVERY injury and illness (including those in and out of season) MUST be reported to an athletic training/sports medicine staff member in a timely manner. Each will be evaluated and a treatment plan will be decided upon. Not every injury will be sent to a doctor. The athletic trainer is trained in triaging injuries and illnesses. We often prefer to ice and rest an injury (sometimes with a protective wrap or splint for up to 72 hours) so that we can compare what we first see with the signs and symptoms that present themselves within the first 2-3 days. At that time, we will make a decision to handle an injury/illness in-house or to refer to our team doctors. We will always err on the side of the athlete’s health and well-being and athletes are encouraged to express any concerns they have with their treatment plan at any time. Please refer to the section on what is/is not covered by STAC athletic insurance.

INSURANCE COVERAGE AT STAC

The STAC Department of Intercollegiate Athletics provides SECONDARY medical insurance coverage for all student-athletes during the playing season (refer to the NCAA manual, Article 17, playing and practice seasons, for a detailed description of allowable practice and competition during a season) provided the injury and/or illness is athletically related. According to the NCAA Bylaw 16.4.1 (h), an athletic-related injury is defined as 'any injury incurred by a student-athlete during intercollegiate practice or competition'. Such injuries will be covered provided the student-athlete is cleared by the NCAA to compete and the injury is reported to the athletic training staff in a timely manner. Athletes must also follow our injury protocol, which always begins with an exam and treatment protocol as decided by the athletic training/sports medicine staff in order to be covered by STAC athletic insurance.

Surgical expenses for a student-athlete (including partial-qualifier or non-qualifier) will be covered provided the student-athlete is injured during the academic year while participating in voluntary physical activities that will prepare the student-athlete for competition. Medical expenses for injury and/or illness that are not a result of athletic-related activities are not covered, nor are they the responsibility of STAC athletics.

All student-athletes must present proof of insurance, either coverage provided by their spouse, parent/guardian, student health insurance, or any other policy before s/he will be allowed to practice or compete in intercollegiate athletics at STAC.

In the absence of primary coverage from the student-athlete, the parent/guardian of the student-athlete, and/or spouse of the student-athlete - the insurance coverage provided by STAC will become primary during the academic year and ONLY for athletic-related injuries/illnesses. ALSO – anyone using the STAC athletic insurance as their primary (due to the fact that they do not have their own primary insurance as previously stated) will only have access to our team physicians for medical treatment unless other arrangements are approved by the STAC athletic department.

The STAC Department of Intercollegiate Athletics will not provide expenses for any injury or illness, which is incurred outside the academic year, during summer weight training and conditioning programs, during pick-up games, or during any other program that is not a regularly scheduled team practice or competition.

NOTE: All medical bill claims and insurance processing is done by the STAC Nurse. It is ultimately the responsibility of the student-athlete to ensure that bills are paid. The STAC Athletic Training/Sports Medicine Staff will assist all student-athletes who are evaluated by our team physicians. We will not provide any assistance for student-athletes who choose to be evaluated and treated by outside medical professionals. Any student-athlete evaluated and treated by outside medical professionals will ultimately need to be cleared by team physicians, at the discretion of the Head Athletic Trainer, before they may return to STAC athletics.

To ensure timely submission of bills, the student-athlete must:

1. Notify the STAC Athletic Training/Sports Medicine Staff of any injury immediately.

2. Provide current and accurate primary medical insurance information.

3. Submit copies of all medical bills and insurance explanation of benefits (EOBs) upon receipt.

4. Follow-up with the Head Athletic Trainer to ensure that the billing process is being initiated.

Things that ARE covered by our SECONDARY athletic insurance policy include, but are not limited to:

▪ Office visits, surgical expenses, and hospital stays as a result of competing in a school-sponsored sport for STAC.

▪ Prescription medication and diagnostic exams when prescribed as a result of competing in a school-sponsored sport for STAC.

▪ Physical therapy/rehabilitation services to outside sources that cannot be completed by the STAC Athletic Training/Sports Medicine Staff when prescribed as a result of competing in a school-sponsored sport for STAC.

▪ Injuries to a student-athlete's mouth, teeth, gums, or jaw which are a direct result of competing in a school-sponsored sport for STAC.

▪ Replacement or repair of glasses or contact lenses, which are broken or lost, provided the break or loss was a direct result of competing in a school-sponsored sport for STAC -OR- if a new eye injury is diagnosed by the STAC Athletic Training/Sports Medicine Staff, which requires corrective or protective eyewear.

▪ Durable goods when prescribed as a result of competing in a school-sponsored sport for STAC provided the STAC Athletic Training/Sports Medicine Staff does not have the desired durable goods available to dispense.

Things that ARE NOT covered by our athletic insurance policy include, but are not limited to:

▪ Bills incurred by non-team physicians if not seen initially by STAC team physicians when directed as a result of competing in a school-sponsored sport for STAC (unless pre-authorized by the STAC Athletic Training/Sports Medicine Staff).

▪ Bills incurred for all 2nd (and beyond) opinions outside of a team physician referral in the event of surgery or not.

▪ Expenses above and beyond the usual and customary charges of your primary insurance plan (ie: it is suggested you stay with in-network doctors/surgeons to minimize the occurrence of such charges).

▪ Prescriptions that are filled without prior authorization by the STAC Athletic Training/Sports Medicine Staff.

▪ Physical Therapy rehabilitation services to outside sources that could have been completed by the STAC Athletic Training/Sports Medicine Staff when prescribed as a result of competing in a school-sponsored sport for STAC.

▪ General dentistry, including teeth cleaning, fillings, tooth extractions, or any other pre-existing conditions, unless the condition has been aggravated as a direct result of competing in a school-sponsored sport for STAC.

▪ Charges for glasses or contact lenses for any student who, upon enrollment at STAC, does not own or have a prior commitment to purchase his/her own glasses or contact lenses.

▪ Durable goods that could have been dispensed by STAC Athletic Training/ Sports Medicine Staff when prescribed as a result of competing in a school-sponsored sport for STAC.

▪ A student-athlete who does not disclose a pregnancy and requests medical attention due to female irregularities will be provided initial medical care. Upon diagnosis of a pregnancy, the student-athlete will be held financially responsible for all continuing medical care.

▪ ANY NON-ATHLETIC INJURIES OR ILLNESSES.

[pic][pic]

Athletic Training/Sports Medicine * 125 Route 340 * Sparkill, New York 10976

STUDENT-ATHLETE SPORTS MEDICINE RECORD

NAME________________________AGE________SEX________DATE OF BIRTH_____________

SPORT(S)____________________SOCIAL SECURITY #_____/____/______ FR SO JR SR GR

IF YOU ARE AN INTERNATIONAL STUDENT – WHAT COUNTRY ARE YOU FROM?___________

MOM/STEPMOM/GUARDIAN__________________________HOME________________________

circle one first last CELL_________________________

WORK________________________

DAD/STEPDAD/GUARDIAN__________________________HOME_________________________

circle one first last CELL__________________________

WORK_________________________

WHO DO YOU LIVE WITH? MOM DAD BOTH GUARDIAN ON OWN

COMPLETE HOME ADDRESS________________________________________________________

YOUR UNITED STATES CELL PHONE NUMBER_________________________________________

********************************************************************************************

OVER-THE-COUNTER, PRESCRIPTION, AND SUPPLEMENT MEDICATION DISCLOSURES

Please list all medications (including over-the-counter, prescribed by a physician, or supplements

and including asthma meds and birth control)

|Medication Name |Dosage |Reason for Taking |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

BY SIGNING BELOW, I UNDERSTAND:

❑ IT IS MY RESPONSIBILITY TO CONSULT WITH MY ATHLETIC TRAINER BEFORE TAKING ANY OVER-THE-COUNTER, PRESCRIBED OR SUPPLEMENT MEDICATIONS TO BE CERTAIN THAT IT IS NOT BANNED BY THE NCAA. _______ INITIALS

❑ FAILURE TO DO SO RISKS LOSS OF NCAA AND/OR STAC ATHLETIC ELIGIBILITY.

_______ INITIALS

❑ IT IS MY RESPONSIBILITY TO UPDATE THIS FORM AS IT BECOMES NECESSARY.

_______ INITIALS

STUDENT-ATHLETE SIGNATURE_______________________________DATE_______________

PICTURE IDENTIFICATION

Please tape or paste a copy of an OFFICIAL PICTURE ID

for this student-athlete

CONSENT FOR TREATMENT

HOW OLD WILL YOU BE ON AUGUST 15, 2017? _______

IF YOU WILL BE UNDER 18 - ANSWER QUESTION #1 AND QUESTION #2

IF YOU WILL BE 18 OR OLDER - ANSWER QUESTION #2 ONLY

1) PARENT/GUARDIAN CONSENT FOR A MINOR

My signature below is to serve as my consent for my son/daughter to be treated by the St. Thomas Aquinas College doctors, athletic training staff, his/her coaches, and any other medical or authorized STAC personnel while on or off STAC campus in the event of an injury.

__________________________ __________________________

print parent/guardian name parent/guardian signature

2) STUDENT-ATHLETE CONSENT

My signature below is to serve as my consent, in the event that I am unable to give verbal consent, to be treated by the St. Thomas Aquinas College doctors, athletic training staff, my coaches, and any other medical or authorized STAC personnel while on or off STAC campus in the event of an injury.

_________________________ __________________________

print student-athlete name student-athlete signature

*************************************************************************************************

HEALTH INSURANCE COVERAGE

1. I AM COVERED BY MY PARENT/GUARDIAN'S INSURANCE POLICY YES NO

2. I AM COVERED BY MY OWN INSURANCE POLICY YES NO

IF YES TO EITHER - ANSWER QUESTION #3 ONLY

IF NO TO BOTH - ANSWER QUESTION #4 ONLY

3. INSURANCE POLICY INFORMATION - PLEASE ANSWER COMPLETELY

All of this information is for the POLICY HOLDER ONLY

POLICY HOLDER______________________SSN______/______/______DATE OF BIRTH__________

EMPLOYER____________________________ADDRESS_____________________________________

INSURANCE COMPANY________________HMO PPO POLICY #_______________ GROUP#________

ADDRESS OF INSURANCE COMPANY____________________________PHONE #________________

NAME AND PHONE # OF THE PRIMARY CARE PHYSICIAN__________________________________

PLEASE PROVIDE A COPY OF ALL INSURANCE CARDS - FRONT & BACK

I HAVE ANSWERED THE ABOVE QUESTIONS TO THE BEST OF MY KNOWLEDGE AND THE ABOVE INFORMATION MAY BE USED IN THE EVENT OF AN EMERGENCY.

POLICY HOLDER SIGNATURE_______________________________DATE_____________

ONLY ANSWER QUESTION 4 - IF YOU HAVE NO HEALTH INSURANCE

4. I CERTIFY THAT I HAVE NO HEALTH INSURANCE COVERAGE; THEREFORE, I WILL BE COVERED BY ST. THOMAS AQUINAS COLLEGE FOR ANY ATHLETIC INJURY.

STUDENT-ATHLETE SIGNATURE______________________________DATE___________

PARENT/GUARDIAN SIGNGATURE_____________________________DATE___________

INSURANCE CARDS

Please tape or paste a copy of the FRONT and BACK of each insurance card

for this student-athlete

MEDICAL HISTORY

Please answer all of the following questions honestly and to the best of your knowledge.

IF ANY reply is YES, you must give a complete explanation on this page, be specific and include dates.

HAVE YOU EVER…

YES NO …HAD DIABETES?

YES NO …HAD EPILEPSY OR A SEIZURE?

YES NO …HAD ASTHMA?

YES NO …BEEN TOLD YOU WERE ANEMIC?

YES NO …HAD MONO OR ANY OTHER INFECTIOUS DISEASE?

YES NO …HAD A HEART MUR-MUR OR HIGH BLOOD PRESSURE?

YES NO …HAD AN ILLNESS REQUIRING BEDREST FOR ONE WEEK OR MORE?

YES NO …BEEN KNOCKED OUT, LOST CONSCIOUSNESS, OR HAD A CONCUSSION?

YES NO …EXPERIENCED SEVERE HEADACHES/MIGRAINES?

YES NO …BEEN AFFECTED BY HOT WEATHER WHEN WORKING OUT?

YES NO …HAD A HERNIA?

YES NO …HAD ANY SURGERY?

YES NO …BEEN TOLD YOU COULD NOT PARTICIPATE IN A SPORT?

YES NO …EXPERIENCED AN ALLERGIC REACTION TO ANYTHING (MEDS/DUST/POLLEN/FOOD)?

YES NO …HAD A BLOOD TRANSFUION?

YES NO …INJECTED ANY SUBSTANCE INTO YOUR BODY?

YES NO …HAD CANCER?

YES NO …HAD A STOMACH PROBLEM?

YES NO …BEEN DIAGNOSED WITH SICKLE-CELL TRAIT/DISEASE?

YES NO …HAD A FAMILY HISTORY WE SHOULD KNOW ABOUT (heart disease/cancer/diabetes)?

YES NO …SEEN ANY PHYSICIAN ON A REGULAR BASIS (Chiropractor/Allergist/Psychiatrist/etc)?

YES NO …HAD BLOOD CLOTTING TROUBLE?

YES NO …HAD DEPRESSION?

YES NO …HAD HEPATITIS/HIV/AIDS?

YES NO …HAD A DENTAL INJURY?

YES NO …FEMALES - DO YOU HAVE ANY PROBLEMS WITH YOUR MENSTRUAL CYCLE?

DO YOU…

YES NO …SMOKE? HOW MUCH? HOW OFTEN?

YES NO …DRINK? HOW MUCH? HOW OFTEN?

YES NO …TAKE ANY MEDICATIONS/ARE THEY LISTED ON THE FIRST PAGE?

YES NO …WEAR GLASSES OR PRESCRIPTION GOGGLES WHILE PARTICIPATING IN SPORTS?

YES NO …WEAR CONTACTS WHILE PARTICIPATING IN SPORTS?

YES NO …WEAR A DENTAL APPLIANCE WHILE PARTICIPATING IN SPORTS?

YES NO …EXPERIENCE ANY OTHER CONDITIONS THAT WE SHOULD BE AWARE OF?

YES NO …UNDERSTAND THE RISKS ASSOCIATED WITH PARTICIPATING IN YOUR SPORT?

*************************************************************************************************

FOR STAC PERSONNEL ONLY

HEIGHT__________WEIGHT__________BP__________PULSE__________FAT %__________

*************************************************************************************************

DR.'S NOTES_______________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

TEAM PHYSICIAN SIGNATURE____________________________DATE_______________

ORTHOPAEDIC HISTORY

Please answer all of the following questions honestly and to the best of your knowledge.

IF ANY reply is YES, you must give a complete explanation on this page, be specific and include dates. We need to know LEFT, RIGHT, BOTH and DIAGNOSIS and YEAR of injuries.

HAVE YOU EVER…

YES NO …HAD AN INJURY TO OR SEEN A DOCTOR FOR YOUR HEAD/NECK/BACK?

YES NO …HAD A SHOULDER DISLOCATION/SUBLUXATION/SEPARATION?

YES NO …INJURED YOUR ROTATOR CUFF/LABRUM?

YES NO …SPRAINED, DISLOCATED, INJURED YOUR ELBOW?

YES NO …BEEN ADVISED TO HAVE SHOULDER/ELBOW SURGERY?

YES NO …INJURED YOUR HAND/WRIST/FINGERS?

YES NO …HAD PAIN IN YOUR HIPS?

YES NO …STRAINED YOUR GROIN/HAMSTRING/QUADRICEPS?

YES NO …SPRAINED A LIGAMENT IN YOUR KNEE?

YES NO …TORN CARTILAGE/MENISCUS IN YOUR KNEE?

YES NO …SUBLUXED OR DISLOCATED YOUR PATELLA/KNEECAP?

YES NO …BEEN ADVISED TO HAVE KNEE SURGERY?

YES NO …HAD OSGOOD-SCHLATTER DISEASE/PATELLA TENDONITIS?

YES NO …HAD SHINSPLINTS?

YES NO …HAD A PROBLEM WITH YOUR ACHILLES TENDON?

YES NO …SPRAINED YOUR ANKLE?

YES NO …HAD A FOOT/TOE INJURY?

YES NO …HAD TENDONITIS/BURSITIS?

YES NO …HAD ARTHRITIS?

YES NO …HAD A FRACTURE/STRESS FRACTURE?

YES NO …BEEN TOLD TO WEAR ANY KIND OF BRACE/GET TAPED?

YES NO …BEEN ADVISED TO HAVE ANY SURGERY?

YES NO …HAD A PIN/SCREW/PLATE PUT IN YOUR BODY FOR ANY REASON?

YES NO …BEEN ADVISED NOT TO PARTICIPATE IN A SPORT?

*************************************************************************************************DR.'S NOTES_______________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

TEAM PHYSICIAN SIGNATURE____________________________DATE_______________

*************************************************************************************************I HAVE ANSWERED ALL QUESTIONS HONESTLY AND TO THE BEST OF MY KNOWLEDGE.

STUDENT-ATHLETE SIGNATURE_______________________________DATE_______________

*************************************************************************************************

STUDENT-ATHLETE IS CLEARED / NOT CLEARED FOR INTERCOLLEGIATE SPORTS PARTICIPATION

ATHLETIC TRAINER SIGNATURE______________________________DATE________________

Student-Athlete Last Name________________

TO BE COMPLETED BY YOUR PERSONAL PHYSICIAN

PLEASE COMPLETE THE FOLLOWING EXAMS AND NOTE ANY ABNORMAL FINDINGS

|MEDICAL | |NORMAL | |ABNORMAL FINDINGS |

|Head/Scalp | | | | |

|Neck | | | | |

|Eyes/Ears | | | | |

|Nose/Mouth/Throat | | | | |

|Heart | | | | |

|Lungs | | | | |

|Abdomen | | | | |

|Skin | | | | |

|Genitalia | | | | |

|ORTHOPAEDIC | | | | |

|Neck | | | | |

|Shoulders | | | | |

|Arms | | | | |

|Wrists/Hands/Fingers | | | | |

|Back/Scoliosis | | | | |

|Hip | | | | |

|Legs | | | | |

|Knees | | | | |

|Ankle/Feet/Toes | | | | |

|FUNCTIONAL TESTS | | | | |

|Spine Range of Motion | | | | |

|Jumping | | | | |

|Hopping | | | | |

|Squatting | | | | |

|Duck Walk | | | | |

YES NO HAVE YOU REVIEWED THIS COMPLETED MEDICAL RECORD WITH THIS STUDENT-ATHLETE?

This Student-Athlete: (check which applies and fill in the blanks as necessary)

_____IS NOT CLEARED FOR INTERCOLLEGIATE SPORTS PARTICIPATION DUE TO____________________

OR UNTIL_______________________

______HAS RESTRICTIONS FOR INTERCOLLEGIATE SPORTS PARTICIPATION______________________

_____IS CLEARED FOR FULL INTERCOLLEGIATE SPORTS PARTICIPATION

PERSONAL PHYSICIAN SIGNATURE/STAMP_________________________________ DATE______________

ASSUMPTION OF RISK

PLEASE READ CAREFULLY AND COMPLETELY

I, (print name)_________________________, wish to participate in the intercollegiate sport(s) of (print sport(s))____________________________, sponsored by St. Thomas Aquinas College. I have participated in this/these sport(s) for approximately (print number) _____years, and I understand there are significant risks involved with my participation. I understand the risks include a full range of injuries, from minor to severe.

These sports-related injuries may be caused by a number of direct and indirect factors, including but not limited to, non-contact causes (twisting around planted foot), contact with various objects (other participants, sports equipment, surfaces or surrounding structures), environmental (heat illness, lightening), or travel (motor vehicle accident).

I also know that this list does not include all risks. There are risks of injuries, which cannot be stated and may be unforeseeable when participating in intercollegiate athletics. I recognize the possibility of the following listed risks and conditions, which include but are not limited to:

_______INITIAL 1. I recognize the possibility that I might die, become paralyzed, or suffer brain

damage or other serious, permanent injury or functional impairment, as a result of

my participation in this sports program.

_______INITIAL 2. I understand there is at least a theoretical risk of blood-borne or other disease

transmission during sports participation.

_______INITIAL 3. I realize that nothing, including the following:

a. the protective equipment and padding used in the sports, b. the safety rules and procedures of the sport,

c. the coaching instruction I receive, or

d. the medical care I am provided will guarantee my safety or prevent all

injuries I might sustain as a result of my participation in intercollegiate

athletics at St. Thomas Aquinas College.

______INITIAL I am now being given the opportunity to ask detailed questions concerning specific risks I may

be unsure about. If I request, a comprehensive sports risk warning presentation will be

provided to me before I participate in my sport. I may ask for such an individual presentation at any time.

______INITIAL I also understand that I can reduce my risk of injury by:

▪ reporting possible illnesses/injuries to, and following the directions of, the STAC Athletic Training/Sports Medicine Staff,

▪ following the skill, technique, and conditioning instruction of my coaches,

▪ following a balanced diet, and

▪ not using/abusing/misusing substances, including over-the-counter or prescription medications, supplements, drugs, alcohol, tobacco, etc.

______INITIAL I have read and understood the sports risk warning information on this form. I agree to accept

these risks and all other risks as a condition of my participation.

DO NOT SIGN THIS FORM IF YOU HAVE ANY QUESTIONS OR CONCERNS!

STUDENT-ATHLETE SIGNATURE________________________DATE______________

PLEASE NOTE:

ALL PAGES OF THIS STUDENT-ATHLETE

MEDICAL PAPERWORK SHOULD BE

BROUGHT WITH YOU TO YOUR

PRE-PARTICIPATION SCREENING EXAM

Including the colored tear away sheets on each of the included NCAA informational packets.

*****

These medical forms DO NOT get mailed back

to the College Nurse.

She will send her own paperwork that

must be returned directly to her office.

*****

If you have any questions or concerns,

please don’t hesitate to contact me

Thank you, Lori

-----------------------

PICTURE ID

DRIVER’S LICENSE

PASSPORT

Other OFFICIAL PICTURE ID

BACK of

CARD #1

FRONT of

CARD #1

BACK of

CARD #2

FRONT of

CARD #2

BACK of

CARD #3

FRONT of

CARD #3

BACK of

CARD #4

FRONT of

CARD #4

How many CONCUSSIONS has this athlete ever been diagnosed with? ____

Dates____________________________

Is this athlete cleared for sports? Y N

If not…why?

Does this athlete have ASTHMA? Y N MUST fill out STAC Asthma treatment plan sheet – Please make sure you get this from the STAC Athletic Training/Sports Medicine Staff and return filled out and signed.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download