examining whether early onset diabetes makes women equally susceptible It is well known that Type I diabetes raises risk for heart disease in women to …
HEALTH RECORD AND QUESTIONNAIRE
Susquehanna University Athletics
PERSONAL This form must be completed and signed by the athlete The last
page MUST be signed by your primary care physician
Name print____________________________________________________
Date_____________________________
Circle one: FR SO JR SR Expected year of graduation_____________
Sports___________________________________
Sex ____________ Date of Birth___________________________
Social Security _____________________________
Residence Hall/Apt
Address____________________________________________________Hall/Aptphone
_________________
Cell phone_____________________
Home
Address___________________________________________________________________
Home Phone_______________
GENERAL If you have had, or now have, any of the following, please mark
and provide a date with the
explanation Any medication currently being taken
should be provided with the reason for and
amount of the medication
Yes No Explain
Allergies
To medication ____
____
___________________________________________________________
Food ____ ____
___________________________________________________________
Insect sting/bites ____ ____
___________________________________________________________
Other ____ ____
___________________________________________________________
Asthma ____ ____
___________________________________________________________
Cancer ____ ____
___________________________________________________________
Cysts or Lumps ____ ____
___________________________________________________________
Diabetes ____ ____
___________________________________________________________
Drug or Alcohol problems ____ ____
___________________________________________________________
Eating Disorder ____ ____
___________________________________________________________
Heart Problems
Dizziness ____ ____
___________________________________________________________
Chest Pain ____ ____
___________________________________________________________
Extra Heart Beat ____
____
___________________________________________________________
Black Outs ____ ____
___________________________________________________________
Heart Murmur ____ ____
___________________________________________________________
Other ____ ____
___________________________________________________________
Herpes ____ ____
___________________________________________________________
High Blood Pressure ____ ____
___________________________________________________________
Infectious Mononucleosis ____ ____
___________________________________________________________
Rheumatic Fever ____ ____
___________________________________________________________
Sickle Cell Trait or Sickle Cell ____ ____
___________________________________________________________
Anemia
Yes No Explain
Have you ever had episodes of
unexplained shortness of breath,
wheezing or chest pain? ____ ____
___________________________________________________________
Are you HIV Positive? ____ ____
___________________________________________________________
Have you ever
had severe pain in ____ ____
___________________________________________________________
your neck or arms?
Medicine taken routinely ____ ____
___________________________________________________________
____________________________________
ABDOMINAL Have you ever had, or now have, any of the following?
Yes No Explain
Appendicitis ____ ____
___________________________________________________________
Stomach Trouble ____ ____
___________________________________________________________
Bleeding from Rectum ____ ____
___________________________________________________________
Blood in Urine ____ ____
___________________________________________________________
Injury to Spleen ____ ____
___________________________________________________________
Hernia ____ ____
___________________________________________________________
Injury to Kidney ____ ____
___________________________________________________________
Bladder or Kidney Problem ____ ____
___________________________________________________________
Please mark YES
if any organs are NOT intact
Yes No Explain
Lungs ____ ____
___________________________________________________________
Kidneys ____ ____
___________________________________________________________
Testes ovaries/testicles ____ ____
___________________________________________________________
Eyes ____ ____
___________________________________________________________
Other ____ ____
___________________________________________________________
____________________________________
NEUROLOGICAL Have you had, or now have, any of the following?
Yes No Explain
Head Injury
Fracture ____ ____
___________________________________________________________
Concussion ____ ____
___________________________________________________________
Unconsciousness ____ ____
___________________________________________________________
Other ____ ____
___________________________________________________________
Neck Injury
Fracture ____
____
___________________________________________________________
Pinched Nerve ____ ____
___________________________________________________________
Yes No Explain
Other ____ ____
___________________________________________________________
Frequent Headaches ____ ____
___________________________________________________________
Seizure Disorder ____ ____
___________________________________________________________
Nervous Disorder ____ ____
___________________________________________________________
____________________________________
ORTHOPEDIC Have you ever had, or now have, an injury to any of the
following? Please note date and
whether injury to right or left side
Yes No Explain
Neck ____ ____
___________________________________________________________
Shoulder ____ ____
___________________________________________________________
Arm/Elbow/Wrist/Hand/Fingers ____ ____
___________________________________________________________
Back/Ribs ____
____
___________________________________________________________
Hip/Groin ____ ____
___________________________________________________________
Thigh ____ ____
___________________________________________________________
Knee ____ ____
___________________________________________________________
Lower Leg ____ ____
___________________________________________________________
Ankle ____ ____
___________________________________________________________
Foot ____ ____
___________________________________________________________
Other Stress Fracture, etc ____ ____
___________________________________________________________
Other health problems including hospitalizations or surgical operations?
If there is other medical history important to your safety or to the safety
of others, please report it below
____________________________________
FEMALES ONLY: Yes No Explain
Have you been treated for a
female disorder ____ ____
___________________________________________________________
Are you pregnant? ____
____
___________________________________________________________
FAMILY HEALTH HISTORY Has any member of your family died from, or do
they now have any of the
following:
Yes No Explain
Heart Disease ____ ____
___________________________________________________________
Diabetes ____ ____
___________________________________________________________
High Blood Pressure ____ ____
___________________________________________________________
Seizure disorders ____ ____
___________________________________________________________
Has any member of your family ____ ____
___________________________________________________________
died suddenly under the age of 50? If yes, give relation, age
and cause of death
____________________________________
PERMISSION FOR MEDICAL RECORDS RELEASE
I hereby authorize Susquehanna Universitys Sport Medicine Staff and
its insurance agent, to inspect or secure copies of the Susquehanna
University Health Centers health record I also consent
for the release
of medical records of past and future confinements and /or disabilities
that may affect my ability to participate in intercollegiate athletic
competition A photo static copy of this authorization shall be deemed as
effective and valid as the original
Signature of Student Athlete for medical records
release__________________________________________Date_______________
____________________________________
ACKNOWLEDGEMENT OF RISK AND INFORMED CONSENT
I realize that participation in any sport can be a dangerous activity
involving MANY RISKS OF INJURY I understand there are risks including and
not limited to death or paralysis, brain damage, cardiac arrest, serious
injury to internal organs and to bones, joints, ligaments, muscles,
tendons, and other serious injury or impairment to other aspects of my
general health and well being I understand that the dangers and risks of
participating in sports also include the potentially high cost of medical
care and impairment of my future ability to earn a living, to engage in
other business, social and
recreational activities, and generally to enjoy
life Recognizing these risks, I choose to participate in the sports of
my choice at Susquehanna University
Student-Athlete
Signature____________________________________________________Date___________
_____
PRIMARY CARE PHYSICIANS MEDICAL CLEARANCE
FOR SPORT PARTICIPATION
DATE____________________ Sport_________________________
Athletes name_____________________________________ has had a complete
physical exam within the past 6 months
Height______________ Weight______________ Blood
Pressure_____________
Nutritional
Status______________________________________________________________________
___________________________
Orthopedic screening findings
or
comments____________________________________________________________________
_______
____________________________________________________________________________
_____________________________________
____________________________________________________________________________
_____________________________________
____________________________________________________________________________
_____________________________________
General Exam findings or
comments____________________________________________________________________
_____________
____________________________________________________________________________
_____________________________________
____________________________________________________________________________
_____________________________________
____________________________________________________________________________
_____________________________________
Athletes clearance for full physical activity check one-
Granted____________
Granted with
restrictions________________________________________________________________
___________________
Postponed
until_______________________________________________________________________
____________________
Rejected____________________________________________________________________
_____________________________
Recommendations_____________________________________________________________
___________________________________
____________________________________________________________________________
____________________________________
____________________________________________________________________________
____________________________________
Physicians Signature___________________________________________________
Date_________________________
Physicians Name Printed_______________________________________________
Physicians office phone ________________________________
Physicians office
address_____________________________________________________________________
____________________
____________________________________________________________________________
___________________________________
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