ANNUAL HEALTH REVIEW

Note: All returning Student-Athletes must complete and return this form to be eligible to participate in intercollegiate athletics.

Name (please print):______Sport______Date______

Residence Hall/Apt. Address______Hall/Apt. phone#______

Cell phone#______Expected Graduation Year______

Year in school (circle one)- Sophmore Junior Senior

Home Phone______Date of Birth______

Home Address______

Height______Weight______Date/Year of last Sports Physical Exam at SU ______

Blood pressure______

Please CIRCLE the correct response. Since your LAST sports physical or “health status” review at Susquehanna have you:

YES NO 1. Had a surgery?

YES NO 2. Had a head injury?

YES NO 3. Had any major injuries?

YES NO 4. Had any serious illnesses or hospitalizations?

YES NO 5. Started any new medications?

YES NO 6. Had any changes in pre-existing health problems?

YES NO 7. Developed any new health problems?

YES NO 8. Seen a physician for anything besides a routine physical or minor illness (such as a cold)?

YES NO 9. Are you currently taking any prescription medications or over the counter medications?

YES NO 10. Do you have any incompletely healed/rehabilitated injuries?

YES NO 11. Do you know of, or believe there is any health reason why you cannot or

should not participate in Susquehanna intercollegiate athletics?

YES NO 12. Did you neglect to adequately train in the off season in preparation for your sport?

YES NO 13. Have any unresolved illnesses or medical conditions?

YES NO 14. Has your insurance information changed?

**If yes, please provide a front and back copy of your new health insurance card**

YES NO 15. Has your home address or emergency contact information changed? If yes, please note below.

Give details for “YES” answers indicated above. Use back of this sheet if necessary.

As a Susquehanna University Student Athlete:

A.  I understand that injuries are an inherent part of athletics and that participation in sports requires an acceptance of risk which includes the possibility of serious injury or death.

B.  I understand that I must refrain from practice or play while ill or injured, until cleared by appropriate clinical practitioners (physicians) and / or their designated representative(s) (Certified Athletic Trainers) whether receiving medical treatment or not.

C.  I understand that having passed the physical examination does not necessarily mean that I am physically qualified to participate in athletics, but only that the evaluator did not find a medical reason for disqualification from participation.

D.  I certify that the answers to the questions above are correct and true.

E.  I understand it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.

I have read and understand the NCAA Concussion Fact Sheet found at www.gosusqu.com/information/sports-medicine/index

After reading the NCAA Concussion fact sheet, I am aware of the following information:

• A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer.

• A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.

• You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

• If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer.

• I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.

• Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve.

• In rare cases, repeat concussions can cause permanent brain damage, and even death.

Date______Signed:______