Athlete Medical Information 2017-2018

Sault College- Athletic Therapy

ATHLETE MEDICAL INFORMATION 2017-2018

Please read all pages in this document carefully and provide requested information and signatures.

It is essential that these forms are completed and returned to the Athletic Therapy Staff before sport participation. If the necessary forms are not on file, or information is incomplete, YOU ARE NOT ABLE TO BEGIN SPORT PARTICIPATION. THERE WILL BE NO EXCEPTIONS.

ATHLETE INFORMATION

Athlete Name: (First Middle Last)

Sport (s):

☐Cross Country ☐Golf

☐Men’s Basketball ☐Women’s Basketball

☐Men’s Indoor Soccer ☐Women’s Indoor Soccer

☐Men’s Hockey ☐Women’s Hockey

☐Curling

Date of Birth: (YYYY-MM-DD)

Health Card Number:

School Email Address:

Alternative Email Address:

Primary Phone Number:

Student-Athlete Name: Date:

EMERGENCY CONTACT 1

Name: Relationship to Athlete:

Address:

City: Province:

Home Phone Contact: Cell Phone Contact:

I understand this individual may be contacted in case of emergency.

EMERGENCY CONTACT 2

Name: Relationship to Athlete:

Address:

City: Province:

Home Phone Contact: Cell Phone Contact:

I understand this individual may be contacted in case of emergency.

Student-Athlete Name: Date: Click here to enter a date.

ATHLETIC INJURY AND MEDICAL POLICIES

SECTION I: Eligibility for Athletic Participation

Paragraph A: All student-athletes desiring to participate in varsity/club athletics must complete the Athlete Medical Information packet in its entirety before being permitted to workout with any Sault College sports team. The paperwork is in effect for one year of completion date.

Paragraph B: Student-athletes who have sustained any injuries, at least one (1) year prior to becoming a team candidate, MUST report these injuries to the Sault College Athletic Training/Therapy staff. Student-athletes who have had any infectious diseases during the previous calendar year must report such illness to the Sault College Athletic Training/Therapy staff. Failure to report such injuries or illnesses relieves Sault College of all liability.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

SECTION II: Liability

Sault College’s liability for medical expenses resulting from injuries and illnesses sustained by Student-Athletes is defined as follows:

Paragraph A: Liability is extended to cover only those injuries reported to the Athletic Training/Therapy staff within three (3) days from the injury producing accident. Liability is further restricted to those injuries received during the Student-Athlete’s season which, in the opinion of the Athletic Training/ Therapy staff and Manager of Athletics, are directly attributable to participation in athletics while enrolled as an eligible student-athlete at Sault College.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

SECTION III: Authorization for Medical Services

Authorization is obtained from the Sault College Athletic Training/Therapy Staff via necessary referrals. If the Athletic Training/Therapy Staff cannot be contacted, the athlete may obtain medical attention on their own; however, the Sault College Athletic Training/Therapy Staff must be notified by the Student-Athlete within seven (7) days of obtaining said services.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

SECTION IV: Responsibility Waiver

As a Student-Athlete at Sault College, the Student-Athlete agrees that Sault College and/or the Department of Athletics and their staff, coaches, Athletic Trainers/Therapists, and employees will not be held responsible for any accidents or loss of personal property, however caused, and agrees to release the College from all claims or damages which may arise as a result of such accidents or loss. It is further agreed that all risk attendant to watching and/or participating in athletics at Sault College, are assumed by the Student-Athlete and his/her parents or guardians and that this assumption is acknowledged, approved by the signature hereto. EACH STUDENT-ATHLETE SHOULD UNDERSTAND THAT THERE ARE INHERENT RISKS ASSOCIATED WITH COMPETING IN ATHLETIC COMPETITION. These risks include, but are not limited to: concussions, lacerations, sprains, strains, fractures, dislocations, subluxations, avulsions, infectious diseases, paralysis, and death.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

SECTION V: Medical Release

I hereby authorize Sault College to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays, and any other data concerning this and/or previous confinements and/or disabilities for return to play status.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

SECTION VI: Consent Authorization

The undersigned hereby further consents to Sault College and its Athletics staff to provide medical treatment and/or care deemed necessary by such staff for the health and well-being of the Student-Athlete participant during the term of his/her participation in athletics at Sault College. This includes the consent to administer any emergency medical treatment or surgical treatment recommended by a physician licensed to practice medicine.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

Student-Athlete Name: Date: Click here to enter a date.

Participants under 17 y of age must also have Parent/Guardian consent for Athletic Injuries & Medical Policies- Sections I to VI.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENTS ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENTS ABOVE.

Parent/Guardian Name: Date: Click here to enter a date.

AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION

Authorization for Release of Medical Information to Sault College Athletic Therapy Staff

Authorization for Release of Medical Information to Referred Medical Professionals

Authorization for Release of Medical Information to Coaches and Athletic/Fitness Staff

Authorization for Release of Medical Information to Parent(s)/Guardian(s)

This document authorizes the Certified Athletic Therapy Staff, Referred Medical Professionals, and Athletics Staff representing Sault College to release pertinent information concerning my medical status, medical conditions, injuries, prognosis, diagnosis, and related personally identifiable health information to the above mentioned. This information includes injuries or illness relevant to past, present, or future participation in Athletics at Sault College.

The reason for this disclosure is to allow such individuals participating in the delivery of Athletic Therapy services to assist and participate in providing healthcare to me while I am a student-athlete.

I understand that I may inspect or copy any information used/disclosed under this authorization.

I understand that I may revoke this authorization at any time by notifying, in writing, the Athletic Therapist and if I do so, it will not have any effect on actions the College took in reliance on this authorization prior to receiving the revocation.

I understand that this authorization expires seven (7) years from the date it is signed unless revoked earlier.

Student-Athlete Name: Date: Click here to enter a date.

Participants under 17 y of age must also have Parent/Guardian consent for Athletic Injuries & Medical Policies- Sections I to VI.

I HAVE READ, UNDERSTOOD, AND ACCEPT THE POLICY STATEMENT ABOVE.

I HAVE READ, UNDERSTOOD, AND DO NOT ACCEPT THE POLICY STATEMENT ABOVE.

Parent/Guardian Name: Date: Click here to enter a date.

GENERAL MEDICAL HISTORY FORM

Please provide explanations to all “YES” answers in the spaces provided.

1. Have you ever been hospitalized?

Yes

2. Have you ever had surgery? (include what type and dates)

Yes

3. Are you currently taking any prescription medications? (please list medications)

Yes

Are you currently taking any over-the-counter medications? (please list medications)

Yes

4. Do you have any allergies (medication, food, etc.)? (explain what reaction occurs and treatment required)

Yes

5. Do you have seasonal allergies (pollen, bee stings, etc.) which require treatment? (explain what reaction occurs and treatment required)

Yes

6. Have you ever been dizzy during or after exercise?

Yes

7. Have you ever passed out during or after exercise?

Yes

8. Have you ever experienced irregular heart beat during or after exercise?

Yes

9. Has a doctor ever denied or restricted your participation in activity due to any heart problems?

Yes

10. Has anyone in your family died of heart issues or sudden death before the age of 50y?

Yes

11. Have you ever had a head injury or concussion? (list how many and dates of injuries)

Yes

12. Have you ever been knocked out or rendered unconscious? (how many times and date of last occurrence)

Yes

13. Have you ever had a seizure or convulsions? (list dates of occurences)

Yes

14. Have you ever had any exercise related dehydration, heat cramps, or heat stroke?

Yes

15. Have you ever been dizzy or passed out in the heat?

Yes

Was the majority of your training done indoors or outdoors?

List the common time of day most of your training occurred

16. Do you have trouble breathing or do you cough or wheeze during or after activity?

Yes

17. Have you ever been diagnosed with asthma?

Yes

18. Do you use an inhaler or other medication for breathing issues? (list type of inhaler/medication)

Yes

19. Have you ever had issues with your eyes or vision?

Yes

20. Do you wear glasses, contacts, or protective eye wear?

Yes

During athletic activity?

21. Have you ever had any significant dental procedures? (explain reason and date of procedures)

Yes

22. Do you wear any removable dental devices or braces?

Yes

23. Have you ever had an injury to your mouth or jaw?

Yes

24. When was your last tetanus shot?

25. Do you currently have any skin conditions (warts, acne, etc.)?

Yes

Do you take any medications for this condition(s)?

Yes

26. Do you require or use any special equipment (orthotics, braces, etc.)? (list and explain)

Yes

27. Have you ever seen a psychologist or mental health counselor?

Yes

28. Have you missed any time from school, work, or sport due to emotional reasons?

Yes

29. Do you smoke cigarettes or use any other type of tobacco product?

Yes

30. Has a physician ever denied or restricted your participation in sports for any reason?

Yes

31. Have you been immunized for:

Hepatitis B Yes No Unsure

Chicken Pox Yes No Unsure

Polio Yes No Unsure

Measles Yes No Unsure

Mumps Yes No Unsure

Rubella Yes No Unsure

32. Do you get a seasonal flu shot?

Yes

Have you had or been diagnosed with any of the following conditions? (Explain all ‘YES’ answers)

Measles NO YES

Mumps NO YES

Chicken Pox NO YES

Rheumatic Fever NO YES

Appendicitis NO YES

Stomach Problems NO YES

Mono NO YES

Tuberculosis NO YES

Hepatitis B NO YES

Hepatitis C NO YES

HIV/AIDS NO YES

Menigitis NO YES

Scarlet Fever NO YES

Pnemonia NO YES

Anemia NO YES

Herpes NO YES

Sickle Cell Trait NO YES

Have you or any member of your family had any of the following medical issues? (Explain ‘YES’ answers)

Diabetes SELF FAMILY

High Blood Pressure SELF FAMILY

Heart Murmur SELF FAMILY

Heart Disease/Attack SELF FAMILY

Liver/Gall Bladder Disease SELF FAMILY

Epilepsy SELF FAMILY

Bruise/Bleed Easily SELF FAMILY

Anemia SELF FAMILY

Tuberculosis SELF FAMILY

Headaches/Migraines SELF FAMILY

Marfan’s Syndrome SELF FAMILY

Kidney/Bladder Infections or Stones SELF FAMILY

Cancer SELF FAMILY

Missing Kidney or any Paired Organ SELF FAMILY

Sudden Death Before Age 50y SELF FAMILY

Other:

Please select any orthopedic injuries you currently or have had in the past. PLEASE SELECT ALL THAT APPLY.

HAND, WRIST, FINGERS

SPRAIN NO RIGHT LEFT BOTH Date of most recent injury:

STRAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

FRACTURE NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

DISLOCATION NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

CHRONIC PAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

SURGERY NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

OTHER: NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

ARM AND ELBOW

SPRAIN NO RIGHT LEFT BOTH Date of most recent injury:

STRAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

FRACTURE NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

DISLOCATION NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

CHRONIC PAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

SURGERY NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

OTHER: NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

SHOULDER AND CLAVICLE

SPRAIN NO RIGHT LEFT BOTH Date of most recent injury:

STRAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

FRACTURE NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

DISLOCATION NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

CHRONIC PAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

SURGERY NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

OTHER: NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

ANKLE, FEET, AND TOES

SPRAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

STRAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

FRACTURE NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

DISLOCATION NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

CHRONIC PAIN NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.

SURGERY NO RIGHT LEFT BOTH Date of most recent injury:Click here to enter a date.