WESTMINSTER COLLEGE ATHLETE PHYSICAL …...Orthopedic Examination – pg 23 ... main medical areas...

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_________________________________ (Athlete Name)

WESTMINSTER COLLEGE

ATHLETE PHYSICAL

EXAMINATION FORM

Checklist (Check box when completed)

For the ATHLETE to complete

Pages 1-8 are for your informational purposes, please remove and keep

Demographic Information – pg 9

HIPPA disclosure and Responsibility to Report forms – pg 10

Assumption of Risk and Consent to Treat form – pg 11

Parent Insurance Form (to be completed by parent) – pg 12

Sickle Cell Form – pg 13

Medical History – pg 14 & 15

Nutrition and Intake Information – pg 16

Pre-existing conditions form – pg 17-19

Orthopedic History – pg 20

Attach a copy of your insurance card (front and back)

For the SPORTS MEDICINE STAFF to complete

Medical Examination – pg 21

Cardiac Clearance – pg 22

Orthopedic Examination – pg 23

Physician Clearance Form – pg 24

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Dear Parents and Student Athletes,

As the sports year approaches, it is necessary for the Westminster College Athletic Department to obtain some

critical information.

As I am sure you are aware, health care costs are a vital concern today. Our student athletes (your son or daughter)

are involved in activities where it may become necessary to require health care services. Westminster College

carries an insurance policy to cover expenses incurred as a result of a student athlete’s athletic related injuries. The

policy provides “excess” coverage only it is considered secondary to all other collectible medical insurance

policies by the student-athlete’s parents, legal guardians, or spouse. This means that any claims must first be filed

with the group insurance company providing coverage to your son/daughter through your employer or spouse’s

employer.

As you may be aware all insurance companies will cover emergency care, but some policies have restrictions on

other medical services outside the state of residence. Because of the rising number and cost of medical claims for

our student athletes, Westminster College is requiring all student-athletes to be covered by a primary

insurance policy which covers office visits to team physicians, scans, x-rays, and hospital visits in the state of

Utah regardless of primary residence. This primary insurance coverage is required to be provided by the

student-athlete or parents no later than the respective student-athletes first practice or first day of 2016 fall

semester classes (August 24, 2016) whichever comes first. This policy must also cover the student-athlete during

their attendance at Westminster College, including their sport in-season and out-of-season. Student-athletes not

meeting this requirement by the date specified above will not be allowed to participate in practices or games until

the requirement is met.

If you need to purchase insurance coverage for Utah, the following sites offer additional information:

https://www.healthcare.gov/

http://www.hhs.gov/healthcare/ (the Utah site)

http://www.dissingerreed.com/university-programs/ (this company has a variety of insurance options for

international student-athletes)

Ascension, the company that is our secondary insurance, has a primary athletic injury only, call 801-412-

2626 and let them know the athlete is a Westminster College athlete.

With a change in Utah law regarding athletic trainers and their ability to bill insurance for services, last summer

the college began billing insurance to offset rising healthcare costs. Please know, your insurance provider will only

be billed when an injury has occurred to your covered son or daughter, and will be billed for treatment directly

associated with the injury. If treatment is provided in a preventative manner, then a charge will not be submitted to

your insurance company. You will receive an EOB, Explanation of Benefits, that will show the amount billed, the

amount covered if any, and a total member responsibility. PLEASE NOTE: Any amount not covered by your

insurance company (member responsibility) will not be billed to the student-athlete or parent(s). We do not expect

parents or student-athletes to pay for any part of these charges. (IMPORTANT: this applies only to treatments

performed by Westminster College Certified Athletic Training staff).

Providing quality preventative and medical services for our student-athletes is of utmost importance to

Westminster College. We appreciate your assistance and understanding with this primary insurance policy

requirement.

https://www.healthcare.gov/

http://www.hhs.gov/healthcare/

http://www.dissingerreed.com/university-programs/

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The college’s insurance policy provides coverage for injuries sustained in Westminster College sanctioned and

supervised practice, competition, and team travel only. The Athletic Department is not financially responsible for

non-athletic related injuries and/or illnesses (e.g. participation in intramurals, accidents, cold/flu, dental, eye care,

etc.) or for pre-existing injuries and illnesses that occur prior to enrollment at Westminster College. Any

qualifying injuries must be reported to the Athletic Training Staff.

The secondary insurance carrier requires that we have on file an updated medical insurance questionnaire. We

recognize that this information may not vary from year to year; however, in some cases it will. Therefore, it is

essential that we have a new record on file each year.

Please take a few moments to carefully fill out the Parent Insurance form and return it to us.

This form must be on file with the Westminster College Athletic Department prior to the beginning of official

practices to insure proper coverage of the student athlete by our secondary insurance provider.

You may return the form along with a copy of their insurance card, front and back, with your student athlete when

they report in for their annual participation physical, or you can mail the form into the athletic training staff using

the address below, or you can print a copy, fill it out, scan it and e-mail it to my email address which is also listed

below. If your son/daughter is under the age of 18 you will also need to sign the other forms list below and

available on the Athletic Training site or provide to your athlete:

Medical Insurance Information

Assumption of Risk

Consent for Treatment

Notice of Privacy Practices / Health Information Disclosure Authorization

Sickle Cell Form

Physical Forms

Parent Insurance Form

I encourage you all to read over the complete packet.

If you have any questions and would like to speak to myself or a member of my staff, please call one of the

numbers below.

HWAC Athletic Training Room 801-832-2341

Payne Athletic Training Room 801-832-2360

Your assistance and cooperation in returning these forms as soon as possible is greatly appreciated. We are all

looking forward to an outstanding year at Westminster College!

Sincerely,

Rick Hackford, MEd, LAT, ATC, LMT

Head Athletic Trainer

Westminster College

1840 S 1300 E

Salt Lake City, UT 84105

[email protected]

Office # 801-832-2355

mailto:[email protected]

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Westminster College

Sports Medicine

Medical Insurance Information

(Please save for future reference)

Athletic Training Room and Staff

Westminster College is concerned with the health of its student-athletes. The Athletic Training Rooms are the

main medical areas for evaluation, treatment, and rehabilitation of all athletic injuries. One athletic training room

is located on the lower level of the Health, Wellness, and Athletic Center (HWAC), the other athletic training room

is located in the lower level of the Payne building. The Athletic Training Rooms are staffed by three full time and

one part-time athletic trainers; all of which are certified by the National Athletic Trainers’ Association and licensed

by the state of Utah. They are assisted by work study students certified in first aid and AED/CPR.

Team Physician and Medical Services

Our Chief Medical Officer and Orthopedic Surgeon here at Westminster College is Dr. Andrew Cooper.

http://www.comporthopedics.com/physicians/cooper_andrew.html

Dr. Joseph Albano, Dr. Stephen Kirk and Dr. Michael Cosgrave are available as primary care and sports medicine

specialists.

We also have a partnership with Sports Med Utah.

http://www.saltlakeregional.com/services/sports_medicine/

Insurance/Medical File

All student-athletes must have the following on file in the Athletic Training Room in order to participate in

intercollegiate athletics at Westminster College:

Physical Examination Form: Arrangements have been made to have the complete physical done here at

Westminster College by our team physician and staff at no expense to the athlete or their parents. It can also be

completed by a personal physician if the athlete and parents choose but the orthopedic portion must be completed

by our team physician or designee. It must then be submitted prior to the beginning of the student-athlete’s sport

season at Westminster College. Student-athletes will also complete a medical history form; this must be done prior

to each season.

Athletic Department Medical Insurance Information: This is a form that provides the Athletic Department and

doctors’ offices/hospitals with your group insurance coverage information. It also serves as an emergency card

that athletic trainers/coaches take with them on road trips in case of an emergency. It must be completely filled

out, leaving no blank lines, and signed by the athlete and/or parent in the case of the athlete being a minor. A copy

of insurance card needs to be attached as added protection for the student-athlete. Additionally, please indicate any

preference of physician or other local medical provider that is covered by your insurance. Student-athletes cannot

participate in any activities related to their sport until this completed form is returned to one of the Certified

Athletic Trainers.

Student-Athlete's Responsibilities Regarding Injuries

When a student-athlete is injured during practice or competition, he/she is responsible to notify the Certified

Athletic Trainer, ATC, covering their sport or the Head Athletic Trainer. If a doctor's attention is required, the

ATC will make the determination at that time and arrange the appointment. Student-athletes must be referred to

a physician by the ATC covering that sport to be eligible for secondary insurance coverage by the college’s

insurance carrier. In the event that emergency treatment is necessary and an ATC is not present, it is the

responsibility of the athlete, coach, and/or parent to contact the Athletic Trainer assigned to their sport. In case of

http://www.comporthopedics.com/physicians/cooper_andrew.html

http://www.saltlakeregional.com/services/sports_medicine/

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extreme emergency, when the Athletic Trainer cannot be reached, the coach may take necessary action to protect

the welfare of the student-athlete. The Athletic Trainer must then be notified as soon as possible.

Westminster College carries a secondary insurance policy to cover expenses incurred as a result of student-athlete's

athletic related injuries. The policy provides "excess" coverage only and is considered secondary to all other

collectible medical insurance policies by the student-athlete's parents, legal guardians, or spouse. This means that

any claims must first be filed with the group insurance company providing coverage to your son/daughter through

your employer or spouse's employer. After the primary carrier has paid all available benefits, our insurance will

pay any remaining amounts for athletic-related injuries only.

The college’s insurance policy provides coverage for injuries sustained in Westminster College sanctioned

and supervised practice, competition, and team travel only. The Athletic Department is not financially

responsible for non-athletic related injuries and/or illnesses (e.g. participation in intramurals, accidents, cold/flu,

dental care, eye care, etc.) or for pre-existing injuries and illnesses that occur prior to participating in athletics at

Westminster College. All injuries must be reported to a Certified Athletic Trainer.

As a student-athlete, your responsibilities are to:

Submit primary health care insurance information to the Athletic Department.

Initiate and obtain a medical referral from the Athletic Trainer when injured during a sanctioned practice or

competition. Without an authorized referral, Westminster College is not financially responsible.

Forward any medical bills associated with the Athletic Department referral to the assigned athletic

trainer at Westminster College. Do not assume that the bill will be "taken care of". Please help us to

stay up to date with all medical bills.

Student-athletes not covered by parents’ or spouse’s insurance must purchase some type of health insurance

that covers athletic injuries in the State of Utah.

THE COLLEGE DOES NOT HAVE THE OPTION TO WAIVE THE REQUIREMENT TO FILE WITH YOUR GROUP

INSURANCE.

1. Most group insurance allows dependent coverage to be continued to age 26 if you are a student. DO NOT

drop from your parents’ policy while you are participating in intercollegiate athletics. It is a college policy

that ALL ATHLETES carry a primary health insurance.

2. By utilizing both your group insurance and our athletic insurance, all authorized athletic injury bills will be

paid in full. You will not be required to pay your group insurance deductible or any coinsurance amounts.

THE FOLLOWING INFORMATION AND AUTHORIZATION MUST BE COMPLETED, SIGNED AND RETURNED TO:

Athletic Training Staff, Westminster College, 1840 South, 1300 East, Salt Lake City, UT 84105 (801) 832-2341 or (801) 832-2360.

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NOTICE OF PRIVACY PRACTICES Westminster College

INTERCOLLEGIATE ATHLETICS

This notice describes how medical information about you may be used and disclosed and how you can gain access to this

information. PLEASE REVIEW IT CAREFULLY.

EFFECTIVE UPON SIGNATURE AND RETURN OF THE DOCUMENT TO

WESTMINSTER COLLEGE

If you have any questions or requests, please contact:

Rick Hackford, ATC


(801) 832-2355

A. We have a legal duty to protect health information about you.

We are required by law to protect the “privacy of health information” (PHI) we have created or received about your past, present or future

health condition, health care we provide to you, and payment of your health care. This document is notice of our legal duties and privacy

practices concerning PHI and is considered as our notification to you about how we protect your PHI. As required by law, this document

will explain how, when and why we use and/or disclose your PHI and ensure that we will only use/disclose PHI described below.

NOTE: Westminster College reserves the right to change the terms of this Notice and to make new notice provisions effective for

all PHI that we maintain by: 1) posting the revised notice in our offices, 2) making copies of the revised notice available upon

request (either at our offices or through the contact person listed in this Notice, and 3) posting the revised notice on our website.

B. We may use and disclose PHI about you without your authorization in the following circumstances:

1. We may use and disclose PHI about you to provide health care treatment to you. We may use and disclose PHI about

you to provide, coordinate or manage your health care and related services. This may include communication with other

health care providers regarding your treatment and coordinating and managing your health care with others. For example,

we may use and disclose PHI about you when you need a prescription, lab work, x-ray, or other health care services. In

addition, we may use and disclose PHI about you when referring you to another health care provider.

2. We may use and disclose PHI about you to obtain payment for services. We may use and give your medical

information to others to bill and/or collect payment for the treatment and services provided to you by us or by another

provider. We may share information regarding scheduled services with your health plan(s), which allows us to ask for

coverage under your plan or policy and for approval of payment before we provide the services. We may also share portions

of medical information about you with the following:

Billing departments

Insurance company or companies associated with Westminster College

Collection departments or agencies, or attorneys assisting us with collections

Insurance companies, health plans and their agents, which provide you coverage

Hospital departments that review care you received to check that it and the costs associated with it were

appropriate for your illness or injury, and

Consumer reporting agencies (e.g., credit bureaus)

3. We may use and disclose PHI under other circumstances without your authorization or an opportunity to agree or

object. Those circumstances include:

When the use and/or disclosure is required by law and/or law enforcement proceedings, correctional institutions

and other law enforcement custodial situations

When the use and/or disclosure is necessary for public health activities

When the disclosure relates to victims of abuse, neglect or domestic violence

When the use and/or disclosure is for health oversight activities

When the disclosure is for judicial and administrative proceedings

When the use and/or disclosure is to avert serious threat to health or safety

When the use and/or disclosure relates to specialized government functions

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4. We may also use or disclose PHI about you in the following circumstances: We may share any injury or illness condition with coaches and other athletic staff in your sport that directly

affects your participation in that sport.

We may share any injury or illness condition with athletic department administration that includes health risks,

drug testing, payment of services, etc.

We may share any injury or illness condition with the athletic department’s sports information director and/or

media outlets upon approval by the head coach of your sport.

We may share any injury or illness condition with amateur athletic organizations upon approval by the head

coach of your sport.

We may share any past or present injury or illness condition with professional athletic teams and their

representatives. We may share any injury or illness condition with your parent/guardian and/or spouse.

Please note the following:

1. You may refuse to sign this authorization. Your refusal will not affect your ability to obtain medical treatment.

2. We may make other uses and disclosures which occur as a byproduct of the permitted uses and disclosure described in this Notice. Under

any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you.

3. Once you sign this authorization, we can rely on it until you revoke it or, if you have not revoked it, until it expires; you can cancel your

authorization in writing by delivering a dated and signed letter to the Head Athletic Trainer addressed to:

Rick Hackford, ATC


Westminster College

1840 South 1300 East

Salt Lake City, UT 84105

If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for

disclosures which were being processed before we received your cancellation.

4. The information authorized for release may include records which indicate the presence of a communicable or venereal disease including,

but not limited to, hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency

Syndrome (AIDS), and/or mental health information.

5. Westminster College will not receive compensation for its use or disclosure of your protected health information.

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Westminster College MEDICAL HISTORY & PRE-PARTICIPATION

PHYSICAL EXAMINATION FORM

DATE: / /

Athlete’s Month Day Year

Name: Sport(s): (Last) (First) (Middle) (Nickname)

Social

Security No: / / Date of Birth: / / / / Month Day Year Age Sex Race

Student ID: Classification: Fr. So. Jr. Sr. Red Shirt Sr. (Different than Social Security No.)

e-Mail Address:

Local Apartment, Address, Dormitory, etc.

Local Phone:

Cell Phone:

I. Person to notify in case

of an Emergency: Relationship:

Address: (City) (State) (Zip)

Home Phone: ( ) Business Phone: ( )

Cell Phone ( ) e-Mail:

II. Father’s Name:

Address:

(City) (State) (Zip)

Employer:_____________________ e-mail:

Home Phone: ( )

Business Phone: ( )

Cell Phone ( )

III. Mother’s Name:

Address:

(City) (State) (Zip)

Employer:______________________ e-mail:

Home Phone: ( )

Business Phone: ( )

Cell Phone ( )

IV. Marital Status

(if applicable) S M W D Separated Spouse’s

Name:

Address: e-Mail: (City) (State) (Zip)

Home Phone: ( ) Business Phone: ( ) Cell Phone: ( )

V. Athlete Insured by: Policy #:

Claims Address: (City) (State) (Zip)

Preauthorization for services required? Prescription Insurance Co: Card #:

Insurance Deductible :

Does Primary Insurance Cover Athletic Injury? _____________________________________________________

*Attach a copy of your insurance card, front and back.*

I hereby certify that the answers provided are true and correct to the best of my knowledge. A photocopy of this authorization shall

be considered as effective and valid.

Date: Signature:

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Injury and Illness Reporting Responsibilities

I, ______________________________, acknowledge that I have to be an active participant in my own healthcare. Therefore I have the

personal responsibility for reporting all of my injuries and illness to the athletic training staff at Westminster College. I recognize that my

true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries

and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose

any future conditions to the athletic training staff at Westminster College.

By signing below, I acknowledge that I have reviewed the NCAA fact sheet on concussions, as included previously in this packet, and

will ask questions about areas of concern that are not clear to me on these issues. I also agree to report any and all injuries or illness that

will have impact on my health care to the Westminster College Athletic Training Staff.

Student Athlete Signature _________________________________________________ Date __________________________________

Parent/Guardian Signature (if under 18 years of age) ____________________________________________________________________

Student Athlete Authorization/Consent For

Disclosure of Protected Health Information to All

I, __________________________(print name), hereby authorize WESTMINSTER COLLEGE and its athletic trainers,

conferences, and other health care personnel to disclose my protected health information and any related information regarding any injury

or illness during my training for and participation in intercollegiate athletics to any of the entities mentioned in the attached PHI Notice

and its employees or agents.

I understand that my injury/illness information is protected by federal regulations under either the Health Information Portability

and Accountability Act (HIPPA) or the Family Education Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be

disclosed without either my authorization under HIPPA or my consent under the Buckley Amendment. I understand that my signing of

the authorization/consent is voluntary and that my institution will not condition any health care treatment or payment, enrollment in a

health plan or receipt of any benefits (if applicable) on whether I provide the consent or authorization requested for this disclosure. I also

understand that I am not required to sign this authorization/consent in order to be eligible for participation in intercollegiate athletics.

This authorization/consent expires at the time that my eligibility in intercollegiate athletics at Westminster College has

exhausted, but I have the right to revoke it in writing at any time by sending written notification to Rick Hackford, Head Athletic Trainer,

at Westminster College. I understand that a revocation is not effective to the extent action has already been taken in reliance on this

authorization/consent.

__________________________________________ _______________________________________

Signature of Student Athlete (or guardian) Date

I, ___________________________, hereby authorize the head coach and/or athletic trainer(s) to release, verbally and/or in writing, to

sports information and/or journalists for purposes related to press releases and/or articles, all information pertaining to injuries/illnesses

that affect my sports participation.

_________________________________________ _______________________________________


I, ______________________, authorize you to furnish and release to Westminster College any and all information concerning me and my

injuries/illnesses in your possession or to which you have access, including but not limited to, any and all records, findings, opinions,

diagnosis or recommendations provided to you by any other doctor, medical or otherwise, any and all invoices, billing statements,

explanation of benefits, or other documents reflecting the value of service rendered. This release also authorizes you and Westminster

College to send any of the information described above to AGIA, Westminster College’s Athletic Insurance Company.

_________________________________________ _______________________________________


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WESTMINSTER COLLEGE

Intercollegiate Athletics

Assumption of Risk

I understand that participation in sports requires a personal acceptance of risk of injury. Athletes generally expect that those who

are responsible for the conduct of sports take reasonable precautions to minimize such risk and that their peers participating in the sport

will not intentionally inflect wrongful injury upon them.

I understand that participation in intercollegiate athletics at Westminster College may result in injury, illness, permanent physical

or mental impairment, or even death. These injuries may be minor or may be career or life threatening. I understand that Westminster

College cannot be held responsible for any injuries or conditions that may be caused by the actions of other athletes or teams. I also

understand that injuries may be caused by my own failure to follow safety procedures or techniques which are made known to me by my

coaching staff, athletic training staff, or by strength and conditioning personnel, or are otherwise known to me from another source.

I understand that there are certain inherent risks involved in participating in intercollegiate athletics. I acknowledge the fact that these

risks exist and I am willing to assume responsibility for any and all such risks while participating in intercollegiate athletics at

Westminster College. I also agree to the following:

1. I voluntarily assume all risks associated with my participation in intercollegiate athletics.

2. I accept that Westminster College and its personnel are not to be held responsible for any pre-existing medical conditions(s) that

I may have.

3. I understand that passing the pre-participation exam does not necessarily mean that I am physically qualified to participate in

intercollegiate athletics at Westminster College, but only that the evaluator did not find a medical reason to disqualify me at the

time of the pre-participation exam.

4. I understand that I must refrain from practices and competition while injured or ill, whether or not receiving medical care. When

under medical care I may not return to participation until I have been given permission by the Certified Athletic Trainer or his

designated representative after review of my condition and fitness for the rigors of my sport. This may occur during or at the

conclusion of medical treatments.

5. I understand and agree that if I experience an injury / illness or change in my health status, it is my responsibility to inform my

Head Coach and the Athletic Training Staff, and to adhere to the established injury management guidelines which include total

rehabilitation and reassessments before I am released to return to full participation.

6. I understand that I must wear the proper equipment as dictated by the rules of my sport. I may also have to wear padding or

braces as indicated by the athletic training staff or medical professional. Failure to do so may put me at risk for further injury.

I HAVE READ, UNDERSTAND, AND VOLUNTARILY AGREE TO THE ABOVE STATEMENTS.

Print Name: ________________________________ Birth Date: ____________________

Sport(s): ________________________________

Signature: ________________________________ Date: ____________________

(Student-Athlete or guardian)

WESTMINSTER COLLEGE Intercollegiate Athletics

Consent for Treatment

I understand that I may be injured while participating in athletics at Westminster College. I authorize the college

to obtain any emergency care that may become necessary while participating in or traveling under Westminster

College’s intercollegiate athletic program. I also authorize Westminster’s athletic trainers to administer those

treatments deemed necessary.

Print Name: ________________________________

Signature: ________________________________ Date:____________________

(Student-Athlete or guardian)

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PARENT’S INSURANCE FORM

Athlete’s Name ____________________________________________________________ SS# _________________________________ Sport _____________________________________________ at Westminster College in Salt Lake City, Utah. Dear Parent:

Every athlete at Westminster College must hold a primary insurance policy that provides for coverage in the state of Utah, including physician office visits, emergency room visits and prescription medication. Our athletic accident policy, which provides insurance for your son or daughter for injuries occurring while participating in the play or practice of intercollegiate sports is “EXCESS” or “SECONDARY” to any other collectible group insurance benefits. This means that any claim for benefits must first be filed with the group insurance company providing coverage to your son or daughter through your employer or your spouse’s employer. After they have paid all available benefits, our athletic insurance company will consider remaining amounts based on USUAL and CUSTOMARY charges. WE, AS THE SCHOOL, DO NOT HAVE THE OPTION OF WAIVING THE REQUIREMENT OF FILING WITH YOUR GROUP

INSURANCE. PLEASE NOTE:

1. Most employers’ group insurance allows dependent coverage to be continued to age 25 if the dependent is a full-time student. DO NOT drop dependent coverage while your son or daughter is participating in intercollegiate athletics. 2. Claims against your group insurance plan DO NOT increase your individual insurance premiums. THE FOLLOWING INFORMATION AND AUTHORIZATION MUST BE FULLY COMPLETED, SIGNED AND RETURNED; please circle the individual listed as the insured on your primary/personal plan and complete all requested information. Father/Guardian/Spouse/Self (circle one)

Name ________________________________________DOB_____________ Social Security # ________________________________

Home Address (Street) (City, State & Zip Code) ______________________________________________________________________

Employer’s Name________________________________ Employer’s Address _____________________________________________

Home Telephone # _______________________________________ Work Telephone #______________________________________

Name of Group______________ Insurance Company _________________________ Group # Policy # __________________________

Mailing Address for Claims _______________________________________________ Telephone #_____________________________

IS YOUR DEPENDENT SON/DAUGHTER COVERED UNDER THE ABOVE POLICY? YES _____ NO _____

Does your insurance require: A second opinion for surgery? YES ___ NO ___ Is your primary insurance an HMO? YES ___ NO ___

Pre-authorization for services? YES ___ NO ___ Is your primary insurance a PPO? YES ___ NO ___

Mother/Guardian/Spouse/Self (circle one)

Name ________________________________________DOB_____________ Social Security # ________________________________

Home Address (Street) (City, State & Zip Code) ______________________________________________________________________

Employer’s Name________________________________ Employer’s Address _____________________________________________

Home Telephone # _______________________________________ Work Telephone #______________________________________

Name of Group______________ Insurance Company _________________________ Group # Policy # __________________________

Mailing Address for Claims _______________________________________________ Telephone #_____________________________

IS YOUR DEPENDENT SON/DAUGHTER COVERED UNDER THE ABOVE POLICY? YES _____ NO _____

Does your insurance require: A second opinion for surgery? YES ___ NO ___ Is your primary insurance an HMO? YES ___ NO ___

Pre-authorization for services? YES ___ NO ___ Is your primary insurance a PPO? YES ___ NO ___

_______ I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained by _____________________________________________. _______ My son/daughter is NOT covered under my group insurance. I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. A photostatic copy of this authorization shall be considered as effective and valid as the original. Date __________________________ Signature of Parent ______________________________________________________________

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Westminster College Sickle Cell Trait Testing Information About Sickle Cell Trait:

Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin.

Sickle cell trait is a common condition

Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait.

Sickle cell trait is usually benign; however during intense or extensive exertion, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells where the shape of the red blood cells change from round to crescent or “sickle” shape. This change, exertional sickling, can pose significant risk for some athletes by causing a “logjam” in the blood vessels leading to collapse from ischemic rhabdomyolysis, (rapid breakdown of muscles starved of blood).

Sickling can begin in 2-3 minutes of all-out exertion.

Heat, dehydration, altitude and asthma can increase the risk for and worsen sickling. Sickle Cell Trait Testing:

Westminster College requires all student-athletes who are beginning their initial season of eligibility and students who are trying out for a team be tested for sickle cell trait, show proof of a prior test or sign a waiver releasing an institution from liability if they decline to be tested.

The Westminster College Department of intercollegiate athletics offers sickle cell screening in the form of a blood test to all student-athletes as part of the pre-participation physical exam process.

Testing will be conducted at the Salt Lake Regional Medical Center Laboratory and/or other designated laboratory facility and results will be reported to the Westminster College Athletic Training Staff and Team Physician.

Sickle Cell Trait Testing Waiver

I, __________________________________, understand and acknowledge that Westminster College will adhere to the NCAA mandate that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about

sickle cell trait, sickle cell trait testing and the risks associated with sickle cell trait.

Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history or knowledge

of sickle cell trait status to the Westminster College athletic training staff and/or team physician.

I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify, defend and hold harmless The Westminster College Board of Trustees, Westminster College, its officers, employees, and agents from

any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury , including serious bodily injury or death, that might result from my non-compliance with the mandate of the NCAA and Westminster College department of intercollegiate

athletics and my voluntary decision to decline sickle cell trait testing.

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.

_____________________________________________ __________________________________________________ Student-Athlete Signature Student-Athlete Printed Name Date

_____________________________________________ __________________________________________________

Sport WC ID#

_____________________________________________ __________________________________________________ Parent/Guardian Signature (if under 18) Date

_____________________________________________ __________________________________________________

Parent/Guardian Printed Name

_____________________________________________ __________________________________________________ Witness Date

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MEDICAL HISTORY Player must answer every question by checking YES or NO. Yes answers require that you fully explain in comment section.

HAD or DO YOU NOW HAVE.. Have you ever had or do you have now…?

YES NO Comment (Give Dates)

Ongoing or Chronic Illness:

Surgery:

Heart Disease:

FOCUSED CARDIO-PULMONARY HISTORY

Present (last 4 weeks) Past (4 weeks or more)

yes no yes no Specify

Heart and lung

Chest pain or tightness

At rest

During or after exercise

Shortness of breath

At rest


Fatigue Easily

Palpitations (irregular heart beat)

At rest


Arrhythmias (rhythm disturbance)

At rest


Dizziness

At rest


Syncope (black outs)

At rest


History of heart murmur

Have you ever had heart problems

or heart surgery,

or seen a cardiologist?

Explain__________________________________________

CARDIAC FAMILY HISTORY (ESP. < 50 Y) yes no Specify

Sudden cardiac death

Sudden infant death

Coronary heart disease or heart attacks

Cardiomyopathy

Hypertension

Recurrent black outs

Arrhythmias Heart transplantation

Heart surgery

Pacemaker/Defibrillator

Unexplained drowning

Unexplained car accident

Stroke

http://dict.tu-chemnitz.de/dings.cgi?o=3003;style=;iservice=en-de;query=dizziness

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Diabetes

Others (cancer etc.)

Marfan syndrome

Long QT syndrome

YES NO ATHLETE’S HISTORY OF

Hepatitis:

Diabetes:

Rheumatic Fever:

Kidney Problems:

Asthma:

Epilepsy:

Sickle Cell Anemia:

Appendicitis:

Hernia:

Frequent Headaches:

Concussion:

Frequent Nosebleeds:

Collapsed Lung:

High Blood Pressure:

Stomach Ulcer:

Mononucleosis:

Intestinal Disorder:

Venereal Disease:

Hives, Rash:

Skin Infection:

Cancer:

Taking Prescription Medications:

Taking Over Counter Medications:

Allergic to Medications:

Allergic to Foods, Insects, Pollen:

Numbness of Hands or Feet:

Heat Illness/Heat Stroke:

Eye Injury or Problems:

Wear Glasses:

Wear Contacts:

Use Tobacco/How Much:

Use Alcohol/How Much:

Use of illicit drugs or narcotics/How Much:

Wear Hearing Aids:

Wear Knee or Ankle Brace:

Excessive Bleeding After Dental Extraction:

***ONLY FEMALES ANSWER THIS SECTION***

GYNECOLOGICAL HISTORY

PLEASE ANSWER EACH QUESTION, CIRCLE YES OR NO WHEN APPROPRIATE. IF THE ANSWER IS YES; WRITE IN THE AGE AT WHICH THE CONDITION OCCURRED. How old were you when you had your first menstrual period? _________________ (age) When was your last period? ________________ (date) How many days are there between your periods from the first day of your menstrual cycle to the first day of your next cycle? ________ 3 days _________ 4-10 days ___________ more than 10 days How many periods have you ad in the past 12 months? ___________________ In the past 6 months? __________________ Have you ever missed 3 or more consecutive months of your menstrual periods? YES NO If yes, how many consecutive months have you missed your period? ______________ Does your menstrual cycle change with a change in the intensity, frequency or duration of training? YES NO If yes, does it become (circle all that apply): LIGHTER HEAVIER SHORTER LONGER DISAPPEAR Do you ever have trouble with heavy bleeding? YES NO Do you ever experience cramps during your period? YES NO If yes, how do you treat them? __________________________________________________________________________________ Are you on birth control pills or hormones? YES NO If yes, which kind? ____________________________________________________________ If yes, were they prescribed for (circle all that apply): Irregular periods No Periods Painful Periods Birth Control When was your last pelvic examination? (date) ____________________________ Have you ever had an abnormal pap smear? YES NO Have you ever had a history of endometriosis? YES NO

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NUTRITION AND INTAKE INFORMATION

Before consuming any nutritional/dietary supplement product, review the product and its label with your athletics department staff. Dietary supplements are not well regulated and may cause a positive drug test result. Any product containing a dietary supplement ingredient is taken at your own risk. (NCAA Sports Medicine Manual, pg 23) PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: 1. _________________________________________________________________________________________________ Dosage: __________________ Reason: ___________________________________________________________ 2. _________________________________________________________________________________________________ Dosage: __________________ Reason: ___________________________________________________________ 3. _________________________________________________________________________________________________ Dosage: __________________ Reason: ___________________________________________________________ 4. _________________________________________________________________________________________________ Dosage: __________________ Reason: ___________________________________________________________ 5. _________________________________________________________________________________________________ Dosage: __________________ Reason: ___________________________________________________________ PLEASE LIST ALL SUPPLEMENTS AND VITAMINS YOU ARE CURRENTLY TAKING: (Including but not limited to: daily vitamins, herbal supplements, pre-workout, muscle builders, etc) 1. _____________________________________________ Purpose: _________________________________________

How often (circle one)? Daily 2-3 times per week weekly monthly cycled Have you checked to see if this product (or it’s ingredients) are on the NCAA banned drug list? NO YES

2. _____________________________________________ Purpose: _________________________________________ How often (circle one)? Daily 2-3 times per week weekly monthly cycled Have you checked to see if this product (or it’s ingredients) are on the NCAA banned drug list? NO YES




Are you currently, or have you in the past year, followed a specific nutrition plan? NO YES How many meals (ie, breakfast, lunch, dinner) do you eat each day? _____________ How many snacks? __________ Are there certain food groups that you refuse to eat (meat, breads, etc)? _______________________________________ Do you ever limit food intake to control weight? NO YES

If yes, do you (check all that apply): _____ decrease the amount of food you eat during the day _____ skip meals _____ limit carbohydrate intake ____ cut out snack items

Are you happy with your current weight? NO YES If not, what would you like to weigh? _________________________ What was the most you’ve weighted in the past year? _______ What is the least you’ve weighed in the past year? ________ Has anyone recommended that you change your weight or eating habits? NO YES If yes, who? __________________ Have you ever tried to lose weight by using any of the following methods? (circle all that apply)

Vomiting Laxatives Diuretics Diet Pills Exercise

Do you regularly exercise outside of your normal practice schedule? NO YES –Describe: __________________

Have you ever been diagnosed with an eating disorder? NO YES

Do you think you might have an eating disorder? NO YES

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NCAA Medical Exemption Documentation Reporting Form

to Support the Diagnosis of Asthma and Treatment with a NCAA banned medication Complete and maintain (on file in the athletics department) this form and required documentation supporting the

medical need for a student-athlete to be treated for asthma with a banned medication

Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the

banned medication (see Drug Free Exemptions Procedures at www.ncaa.org/drugtesting).

To be completed by the Institution:

Institution Name: ________________________________________________________________________________

Institutional Representative Submitting Form:

Name: ______________________________________________________________________________________

Title: _______________________________________________________________________________________

Email: ______________________________________________________________________________________

Phone: _____________________________________________________________________________________

Fax: ________________________________________________________________________________________

Student-Athlete Name: ___________________________________________________________________________

Student-Athlete Date of Birth: ______________________________________________________________________

To be completed by the Student-Athlete’s Physician:

Current Treating Physician (print name): ______________________________________________________________

Specialty: ______________________________________________________________________________________

Office address: __________________________________________________________________________________

Office phone number: ____________________________________________________________________________

Physician signature: ______________________________________________________________________________

Check off that documentation representing each of the items below is attached to this report

o Diagnosis

o Medication(s) and dosage

o Blood pressure and pulse readings and comments

o Note that alternative non-banned medications have been considered, and comments

o Follow-up orders

o Date of clinical evaluation: ________________________

o Attach written report summary of comprehensive clinical evaluation. Please note that this includes the

original clinical notes of the diagnostic evaluation.

The evaluation should include individual medical and treatment history. Attach supporting documentation and

testing. The evaluation must be completed by a clinician capable of meeting the requirements detailed above.

***When completed please return to the institutional representative listed above with all documentation necessary.

Disclaimer: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or

other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in

reliance upon the accuracy or veracity of the information provided hereunder.

http://www.ncaa.org/drugtesting

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If you have any pre-existing conditions please have this form filled out by your physician overseeing your care. A

new form must be completed for any change in medication or treatment protocol. Pre-existing conditions

include, but are not limited to, asthma, diabetes, cardiovascular, sickle cell anemia, mental health disorders,

ADHD/ADD treatments and medication, testosterone treatment via medications, etc.

**You will need one form for each medical condition. Please make copies and attach as needed.

**If you do NOT have any pre-existing medical conditions please list “none” and sign the form.

This form will also serve as part of the needed documentation for NCAA banned drugs being used therapeutically

under the supervision of a physician.

You must provide extras of medication (inhalers, insulin, prescription medications) and all other treatment

devices (spacers for asthma, blood glucose strips, etc) to be carried by your athletic trainer at all times. You are

expected to carry your own medications as well, and rely on the supplies your athletic trainer carries as backup,

plan ahead to bring two complete sets with you when you report for your sport. You will not be cleared for

athletic participation until this form and a set of needed medication/devices are provided.

Athlete Name: _____________________________________________ Date: ___________________________

Sport: _______________________ Date of Birth: ______________ School year FR SO JR SR

Medical Condition:_________________________________________________________________________

Medication prescribed: include medication name and dosage. Attach copies of prescriptions.

1. ___________________________________________________________________________

2. ____________________________________________________________________________

3.____________________________________________________________________________

Physician name: ____________________________________________________________________________

Contact phone number: _____________________ Address: ________________________________________

(see reverse side for prevention/treatment/RTP plans)

Student Athlete Pre-Existing Condition Form Westminster College Sports Medicine Department

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Please describe the PREVENTION plan as agreed on between student-athlete and treating physician:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________

Please describe the TREATMENT plan as agreed on between student-athlete and treating physician:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________

Please describe the RETURN TO PLAY GUIDELINES as agreed on between student-athlete and treating physician:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________

Physician Signature: _______________________________________________________Date: ____________

Athlete Signature: _______________________________________________________Date: ____________

Please contact your Westminster College Athletic Trainer if you have any questions or need assistance. Their phone numbers and emails can be found on the Westminster College Athletics Webpage.

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_________________________________ (Athlete Name)

ORTHOPEDIC HISTORY Player must answer every question by checking YES or NO. Yes answers require that you fully explain in comment section.

NOTE: If you are a NEW ATHLETE to Westminster College please complete questionnaire pertaining to your entire life until this date.

If you are a RETURNING ATHLETE, please complete this questionnaire pertaining to the last year, since your previous physical.

HAVE YOU EVER HAD or DO YOU NOW HAVE... ?

Have you ever had or do you have now and injury to your…?

Yes No Comments (Give Dates)

Neck:

Shoulder:

Upper arm:

Elbow:

Forearm:

Wrist:

Hand or fingers:

Abdominal muscles:

Chest or ribs:

Back:

Hip:

Groin:

Thigh:

Hamstring:

Knee:

Lower leg:

Ankle:

Foot or toe:

Orthopedic surgery:

A pin, plate or screw in your body:

Advised to have surgery but didn’t:

Additional Comments:

Stop here! Please do not complete anymore.

The remainder of this form is for the sports medicine staff to complete.

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_________________________________ (Player Name)

MEDICAL EXAMINATION

Height: Weight:

B/P: HR: Drug Allergy:

Visual Acuity Right Eye: Left Eye: Corrected?

Normal Abnormal Comments

General Appearance:

Head:

Eyes:

Ears, Nose, Throat:

Neck:

Chest:

Heart:

Heart rrhythm Normal Abnormal

Heart murmur Normal

Systolic murmur grade 2 or less Yes No Location_____

Systolic murmur grade 3 or more Yes No Location_____

Does murmur increase with Valsalva? Yes No

Diastolic murmur Yes No Location_____

Delay in femoral pulses? Yes No

Marfan Criteria (Chest deformities, long arms and legs, flat footedness, scoliosis.

lens dislocation etc):

Yes No

If yes, specify:

Pulses:

Abdomen:

Hernia:

Genital:

Skin:

Lymphatic:

Additional Comments:

Examining Physician: __________________ (print clearly) (date)

(signature)

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CARDIAC CLEARANCE DECISION TREE

CARDIAC CLEARANCE DECISION

Current Risk Rating (circle one): 0: Minimal Risk: No history of heart disease or symptoms, negative family history, normal examination.

1: Low Risk: CLEARED

a. History of grade 2 or less systolic murmur which does not increase with Valsalva

b. Corrected heart disease for which Bethesda Guidelines allow play

c. Treated blood pressure ≤140/90 mmHg

d. Positive family history, but unlikely to have inherited heart disease

e. B/P > 140/90 note: ________________________________________________

2: Significant Risk (circle any or all that apply): NOT CLEARED

a. More than 10mm Hg difference in B/P in arms

b. Cardiac symptoms suspicious for underlying heart disease

c. Delay in femoral pulses

d. Grade 3 or more systolic murmur, or murmur that increases with Valsalva

e. Diastolic murmur

f. Positive answers to family history, likely to have inherited heart disease

g. Positive answers to pre-existing heart disease for which Bethesda Guidelines do not allow play

h. Stigmata of Marfans

**If participant has been deemed NOT CLEARED, must complete phase 2 examination and must

circle category five on general clearance **

If any of the above are circled, player will require further workup before return to play is allowed.

Comments:

Player Name: ______________ (print clearly) (date)

Recommended By: (print clearly) (date)

Signature:

Cardiovascular System

Heart rate at rest …………BPM Cardiology work up if resting

HR less than 40 or greater than

100 beats/min

Blood pressure at rest (supine) right arm …………mmHG Cardiology work up if BP ≥

140/90

History (see answers to heart

questions in player history)

normal

abnormal or positive (requires

Cardiology work up)

Physical exam ( see heart exam)

normal

abnormal or positive (requires

Cardiology work up)

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_________________________________ (Player Name)

ORTHOPEDIC EXAMINATION NOTE: If a NEW ATHLETE to Westminster College please complete questionnaire pertaining to their entire life until this date.

If a RETURNING ATHLETE, please complete this questionnaire pertaining to the last year, since their previous physical.

Normal Abnormal Comments

Neck:

Shoulder Right:

Shoulder Left:

Elbow Right:

Elbow Left:

Wrist Right:

Wrist Left:

Hand/ Fingers Right:

Hand/ Fingers Left:

Back:

Hip Right:

Hip Left:

Groin Right:

Groin Left:

Quad/ Hamstring Right:

Quad/ Hamstring Left:

Ankle Right:

Ankle Left:

Foot/ Toes Right:

Foot/ Toes Left:

Knee Right:

ROM:

Effusion:

McMurray’s:

Patella:

ACL / PCL:

MCL / LCL:

Knee Left:

ROM:

Effusion:

McMurray’s:

Patella:

ACL / PCL:

MCL / LCL:

Examining Physician: (print clearly) (date)

(signature)

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(Player’s Name)

PHYSICIAN’S REPORT

Check One

CLEARED - I have examined the above-listed athlete and found him/her to have NO physical injuries, orthopedic problems, or

conditions that would prevent him/her from unlimited participation in collegiate athletics.

NOT CLEARED - I have examined the above-listed athlete and found him/her to have orthopedic conditions or problems,

detailed in the appropriate area below, which need ongoing medical treatment or rehabilitation.

a. Estimated time of recovery from the date of this examination:

b. Proposed treatment plan and time frame for rehabilitation:

c. Proposed date for re-examination:

Examining Physician:

(Print clearly) (Date)

(Signature)

WESTMINSTER COLLEGE ATHLETE PHYSICAL …...Orthopedic Examination – pg 23 ... main medical areas...

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