Shaw Athletics



Last Name (printFirst NameMiddle InitialSocial Security NumberHome Address (Number & Street)CityStateZip Telephone NumberDate of BirthGenderMarital StatusYear of GraduationSemester of RegistrationInsurance CompanyPolicy NumberHave Any of Your Relatives Ever Had Any of The Following?YesNoRelationshipTuberculosisDiabetesHeart DiseaseKidney DiseaseArthritisStomach DiseaseAsthma, Hay FeverEpilepsy, ConvulsionsName/ Relationship of Next of KinPARENTS OF STUDENTS UNDER 18: I hereby authorize any medical treatment for my son/daughter which may be advised or recommended by the physicians of the Student Health Service or Sports Medicine Department of Shaw University_______________________________________________Signature of Parent/GuardianDateAddress/Phone of Next of KinPERSONAL HISTORYPLEASE ANSWER ALL QUESTIONSComment on all positive answers in space below or on additional sheetHave You HadYesNoHave You HadYesNoHave You HadYesNoHave You HadYesNoEye TroubleFrequent or sever Respiratory InfectionsKidney or Bladder DiseaseDiabetesEar, Nose, ThroatRheumatic Fever or Heart MummerDisease or Injury of Bones or jointsInfect. MononucleosisFrequent or Sever HeadachesStomach or Intestinal Trouble“Trick” Knee or ShoulderSickle AnemiaEpilepsyFemales onlyAsthma, Hay fever, HivesHepatitis or JaundiceAsthma Irregular PeriodTuberculosis Severe Cramps Excessive FlowYesRemarks or Additional Information(Use Extra Paper if Necessary)NoDo you have any disease, or is any drug or other treatment being followed, which should be continued or periodically evaluated? (Details)Have you any drug allergy or other known sensitivity or intolerance? (Details)Have you had any illness, injury, or operation or been hospitalized other than as already noted? (Details)Has your physical activity been restricted during the past five years? (Why)Have you ever been hospitalized for mental or emotional illness? {Give Names and address of doctors and/or hospitals}Statement by Student: I have personally supplied the above information and attest that it is true and complete to the best of my knowledge. I hereby give my permission to any doctor, hospital, or other medical agency to release confidentially to the Student Health Service Physician(s) or Sports Medicine Staff of Shaw University any information they may have concerning my medical condition and their professional contact with me.A photocopy of this permission is considered as valid as original.____________________________________________________Signature of Student DateHave you ever interrupted school or work either because of mental or emotional illness or after psychiatric consultation? {Give Names and address of doctors and/or hospitals}___________________________________________________________________Physician’s Signature (Acknowledging Review)DateTo the Examining Physician: Please review the student-athletes history and complete the physician’s form. Please comment on all positive answers. The information supplied will be used as a background for providing health care. This information is strictly for Sports Medicine and will not be released without the students consent.Last NameFirst NameMiddle NameHeight: __________ InchesWeight: ___________lbs. B.P. ________/________Pulse: ___________min.Corrected Vision:Hearing (gross):Right:____________Left: ____________Right: ____________Left: ____________UrinalysisSugar: ______________Albumin: __________________Micro: __________________Hematocrit (if indicated Sickle Cell:____________________%VaccineDateDateDateDateDateDTPTd or Tetanus BoosterPolio, oralRubeola (measles, MMR)Disease DateDisease DateMumps (MMR)Rubella (German measles, MMR) Is there loss or seriously impaired function of any paired organ? _____________________________________Have you any general comments? ______________________________________________________________Recommendation for physical activity (sports)? Unlimited ________________ Limited ___________________Do you have any recommendations regarding the care of this Student Athlete? Yes ________ No __________Is the student now under treatment for any medical or emotional condition? Yes _________No _______________________________________________________Signature of physician/pa/npDateAre there any abnormalities?YesNoHead, Ears, Nose, ThroatEyesRespiratoryCardiovascularGastrointestinalHerniaGenitourinaryMusculoskeletalShouldersHipsKneesAnklesFeetMetabolic/EndocrineNeuropsychiatricSkinMammaryIs there loss or seriously impaired function of any paired organ? _______________________________________Have you any general comments? _______________________________________________________________Recommendation for physical activity (Sports) Unlimited ___________ _____Limited ______________________Do you have any recommendations regarding the care of this student? Yes ____________ No_______________Is the student now under treatment for any medical or emotional condition? Yes ___________ No _____________________________________________________________Signature of Physician/PA/NP Date ................
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