MNU paperwork cover NEW 2015-2016.pdf (P)€¦ · Have you had herpes or MRSA skin infection? M23 Do you have frequent changes in your sleeping patterns? M24 Do you have a history

MNU ATHLETIC TRAINING

2015/2016

STUDENT-ATHLETE DEMOGRAPHIC INFORMATION

Name:___________________________________________________________ Male / Female (CIRCLE) (FIRST) (MIDDLE) (LAST)

Year of Eligibility: FR SO JR SR 5thSR (CIRCLE) Sport: Cheer FB SB MBB WBB BB VB MSOC WSOC (CIRCLE)

Date of Birth:_____________ SS#:_____________________ M#:________________________

(1) Local/Campus Address: Box #/Apt #:

City/State/Zip:

Cell Phone #:

Email address:

(2) Permanent Address: Box #/Apt #:

City/State/Zip:

Phone Number:

EMERGENCY CONTACT INFORMATION

PRIMARY CONTACT SECONARDY CONTACT

Name: Name:

Relationship to

Student-Athlete:

Relationship to

Student-Athlete:

Phone (CELL): Phone (CELL):

Phone (HOME): Phone (HOME):

Phone (WORK): Phone (WORK):

Email: Email:

INSURANCE INFORMATION Who is the owner of your primary insurance policy? (CHECK ONE)

� Self

� Parent/Guardian (if you check this box you MUST complete the box below)

Name: Relationship to Student-Athlete:

Date of Birth: Social Security #:

Address: City, State, Zip:

Phone (CELL): Phone (HOME):

Phone (WORK): Email:


2015/2016

______________________________________________ (INSERT NAME: LAST, FIRST MIDDLE)

1

MEDICAL HISTORY FORM

TODAY’S DATE: ______________

NAME (Last, First, Middle):___________________________________________________________________

DOB:__________________ ELIGIBILITY: FR SO JR SR 5thSR SEX: M F

Sport: FB VB MSoc WSoc MBB WBB Cheer SB BSB

Please list ALL of the prescription and over-the-counter medicines (herbal and nutritional) that you are currently taking.

MEDICATION/SUPPLEMENT DOSAGE HOW OFTEN?

ALLERGIES YES NO What Specifically?

Food

Pollens

Medicines

Stinging Insects

Other?

Explain “YES” answers at end.

All questions must be answered. GENERAL QUESTIONS

Please explain “yes” answers in space at end Yes No

G1 Has a doctor ever denied or restricted your

participation in sports for any reason?

G2 Have you ever spent the night in the hospital?

G3 Have you ever had surgery?

G4 Have you been advised to have surgery that you

did not have?

G5 Are you currently under the care of a physician or

medical professional for any injury or illness?

MEDICAL QUESTIONS


M1 Do you have asthma?

M2 Do you have anemia?

M3 Do you have diabetes?

M4

Do you have any other type of on-going

illness/disease? If so, please specify:

_____________________________________

M5 Do you have or have you been treated for a

mental illness?

M6 Have you been to or received counseling for any

mental illness/anxiety/eating disorder?

M7 Have you ever been tested for sickle cell trait?

M8 Have you ever been told that you have sickle cell

trait/disease?

M9 Have you ever become ill while exercising in the

heat?

M10 Do you get frequent cramps when exercising?

M11 Do you cough, wheeze, or have difficulty

breathing during or after exercise?

M12 Do you use or require any hearing aid device (s)?

M14 Do you wear glasses either in sport or activities of

daily living?

M15 Do you use contacts either in sport or activities of

daily living?

M16 Have you ever had problems with your eyes or

vision?

M17 Do you wear protective eyewear, such as goggles

or a face shield?

M18 Were you born without or are you missing a

kidney, an eye, your spleen, a testicle (male), a


2015/2016

______________________________________________

(INSERT NAME: LAST, FIRST MIDDLE)

2

ovary (female) or any other organs?

M19 Do you have groin pain or a painful bulge or

hernia in the groin area?

M20 Have you had infectious mononeucleosis (mono)

within the last month?

M21 Do you have any rashes, pressure sores, or other

skin problems?

M22 Have you had herpes or MRSA skin infection?

M23 Do you have frequent changes in your sleeping

patterns?

M24 Do you have a history of seizures?

M25 Do you suffer from uncontrolled mood swings?

M26 Do you have frequent headaches?

M27 Do you worry about your weight?

M28 Has anyone ever told you that you need to lose or

gain weight?

M29 Are you on a special diet or do you avoid certain

types of foods?

M30 Have you ever had an eating disorder?

M31 Have you ever been treated for or are you

currently being treated for an STD?

HEART HEALTH QUESTIONS ABOUT YOU


He1 Have you ever passed out or nearly passed out

DURING or AFTER exercise?

He2 Have you ever had discomfort, pain, tightness, or

pressure in your chest during exercise?

He3 Do you get lightheaded or feel more short of

breath than expected?

He4 Does your heart ever race or skip beats during

exercise?

He5 Has a doctor ever told you that you have heart

problems?

He6 Has a doctor ever told you that you have high

blood pressure?

He7 Has a doctor ever told you that you have high

cholesterol?

He8 Has a doctor ever told you that you have a heart

murmur?

He9 Has a doctor ever told you that you have a heart

infection?

He10 Has a doctor ever told you that you have

Kawasaki Disease?

He11 Has a doctor ever told you that you have any

other heart problem not listed?

He12 Has a doctor ever ordered a test for your heart?

(i.e., ECG/EKG, echocardiogram)

He13 Have you ever had an unexplained seizure?

He14 Do you get more tired or short of breath more

quickly than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY


HH1

Has any family member or relative died of heart

problems or had an unexpected or unexplained

sudden death before the age of 50 (including

drowning, unexplained car accident, or sudden

infant death syndrome)?

HH2

Does anyone in your family have hypertrophic

cardiomyopathy, Marfan syndrome,

arrhythmogenic right ventricular cardiomyopathy,

long QT syndrome, short QT syndrome, Brugada

syndrome, or catecholaminergic polymorphic

ventricular tachycardia?

HH3 Does anyone in your family have a heart problem,

pacemaker, or implanted defibralator?

HH4

Has anyone in your family had unexplained

fainting, unexplained fainting, unexplained

seizures, or near drowning?

OTHER FAMILY HEALTH QUESTIONS


Does anyone in your family have the following

illnesses/diseases:

Fa1 Cancer?

Fa2 Coronary Heart Disease?

Fa3 High Blood Pressure?

Fa4 Diabetes?

Fa5 Kidney disease?

Fa6 Sickle cell trait/disease?

Fa7 Stroke?

Fa8 Epilepsy?

Fa9 Mental Illness?

Fa10 Asthma?

CONCUSSION HISTORY


C1 Have you ever had a head injury or concussion?

C2 How many concussions?

C3

Have you ever had a hit or blow to the head that

caused confusion, prolonged headache, or

memory problems?

C4 Have you ever been unable to move your arms or

legs after being hit or falling?

C5 Have you ever seen a doctor about a concussion

or head injury?

FEMALES ONLY

Please explain “yes” answers for questions Fe4-7 in space at

end

Yes No

Fe1 Have you ever had a menstrual period?

Fe2 How old were you when you had your first

menstrual period

Fe3 How many periods have you had in the last 12


2015/2016

______________________________________________


3

months?

Fe4 Do you have frequent menstrual cramping?

Fe5 Have you ever been pregnant?

Fe6 Do you have menstrual irregularities?

Fe7 Do you have loss of menstrual cycles?

ORTHOPEDIC HISTORY AND INJURIES

Please explain “yes” answers in space at end

Neck Yes No

N1 Muscle Strains?

N2 Nerve Complications?

N3 Sprains/Disk Injuries?

N4 Injections?

N5 Fractures?

N6 Surgery?

N7 Hospitalized?

N8 Un-resolved Pain?

Upper Back Yes No

UB1 Muscle Strains?

UB2 Nerve Complications?

UB3 Sprains/Disk Injuries?

UB4 Injections?

UB5 Surgery?

UB6 Hospitalized?

UB7 Un-resolved Pain?

Shoulders Yes No

S1 Muscle Strains?

S2 Nerve Complications?

S3 Dislocations?

S4 Tendonitis?

S5 Bursitis?

S6 Sprains/Separations?

S7 Injections?

S8 Fractures?

S9 Hospitalized?

S10 Surgery?

S11 Un-resolved Pain?

Elbows Yes No

E1 Muscle Strains?

E2 Nerve Complications?

E3 Dislocations?

E4 Tendonitis?

E5 Bursitis?

E6 Sprains/Hyperextenions?

E7 Injections?

E8 Fractures?

E9 Hospitalized?

E10 Surgery?

E11 Un-resolved Pain?

Hands/Fingers Yes No

HF1 Muscle Strains?

HF2 Nerve Complications?

HF3 Dislocations?

HF4 Tendonitis?

HF5 Bursitis?

HF6 Sprains/Hyperextenions?

HF7 Injections?

HF8 Fractures?

HF9 Hospitalized?

HF10 Surgery?

HF11 Un-resolved Pain?

Wrist Yes No

W1 Muscle Strains?

W2 Nerve Complications?

W3 Dislocations?

W4 Tendonitis?


2015/2016

______________________________________________


4

W5 Bursitis?

W6 Sprains/Hyperextenions?

W7 Injections?

W8 Fractures?

W9 Hospitalized?

W10 Surgery?

W11 Un-resolved Pain?

Arms Yes No

A1 Muscle Strains?

A2 Fractures?

A3 Surgery?

A4 Hospitalized?

A5 Un-resolved Pain?

Low Back Yes No

LB1 Muscle Strains?

LB2 Nerve Complications?

LB3 Sprains/Disk Injuries?

LB4 Injections

LB5 Fractures?

LB6 Surgery?

LB7 Hospitalized?

LB8 Un-resolved Pain?

Pelvis/Hips Yes No

PH1 Muscle Strains?

PH2 Hip Pointers?

PH3 Nerve Complications?

PH4 Dislocations?

PH5 Tendonitis?

PH6 Bursitis?

PH7 Groin “pulls” or tears?

PH8 Injections?

PH9 Fractures?

PH10 Hospitalized?

PH11 Surgery?

PH12 Un-resolved Pain?

Thighs/Femur/Upper Leg Yes No

T1 Quadriceps Strains?

T2 Hamstring Strains?

T3 Muscle Tears?

T4 Injections?

T5 Fractures?

T6 Hospitalized?

T7 Surgery?

T8 Un-resolved Pain?

Knees Yes No

K1 Sprained Ligaments

K2 Torn Ligaments

K3 Torn cartilage

K4 Patella injury

K5 Dislocations

K6 Non-Specific sprains

K7 Chronic swelling

K8 Feelings of "locking” or “giving away”?

K9 Injections?

K10 Fractures?

K11 Hospitalized?

K12 Surgery?

K13 Un-resolved Pain?

K14 Do you wear knee braces?

Shins/Lower Leg Yes No

LL1 Shin Splints

LL2 Muscle Tears?

LL3 Injections?

LL4 Fractures?


2015/2016

______________________________________________


5

LL5 Hospitalized?

LL6 Surgery?

LL7 Un-resolved Pain?

Ankles Yes No

A1 Sprains?

A2 Torn ligaments?

A3 Nerve Complications?

A4 Dislocations?

A5 Tendonitis?

A6 Chronic Swelling?

A7 Injections?

A8 Fractures?

A9 Hospitalized?

A10 Surgery?

A11 Un-resolved Pain?

A12 Do you wear ankle braces or tape?

Feet/Toes Yes No

F1 Muscle strains?

F2 Sprains?

F3 Stress Fractures?

F4 Muscle Tears?

F5 Injections?

F6 Fractures?

F7 Hospitalized?

F8 Surgery?

F9 Unresolved pain?

F10 Do you wear orthotics?

END

Please explain ALL “Yes” answers (if applicable)

For all applicable questions be sure to specify LEFT or RIGHT

Question # Explanation


2015/2016

______________________________________________


6

I hearby state that, to the best of my knowledge, my answers to the questions on this medical

history form are complete and correct.


2015/2016

______________________________________________


7

__________________________________ _________________________________ _________________ Print Name Signature of Student-Athlete Date

If under 18 years old this must be signed by a parent or guardian.

__________________________________ _________________________________ _________________

Print Name Signature of Parent/Guardian Date


2015/2016

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Section A: Patient Giving Consent (PLEASE PRINT)

NAME: _______________________________________________________________________

CELL PHONE: __________________________________________________________________

M# _______________________________________ SSN: ______________________________

Section B: To the Patient – PLEASE READ THE FOLLOWING STATEMENT CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your health information to carry out

treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign

this Consent. Our Notice provides a description of the use and disclosures we may make of your health care information

including our treatment, payment activities, healthcare operations, and of other important matters about your health

information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before

signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our

privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may

apply to any of your health information that we maintain.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation

submitted to the MNU’s Director of Sports Medicine. Please understand that revocation of this Consent will not affect any

action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to

continue treating you if you revoke this Consent.

SIGNATURE: * (Please sign both signature boxes below)*

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I

understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my health information

to carry out treatment, payment activities, and health care operations.

_______________________________________ ___________________________________ __________________ Print Name Signature of Student-Athlete Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received a copy of MNU Athletic Training’s Notice of Privacy Practices.

_______________________________________ ____________________________________ ___________________ Print Name Signature of Student-Athlete Date


2015/2016

PERMISSION TO RELEASE MEDICAL INFORMATION FROM OUTSIDE PROVIDER TO

MIDAMERICA NAZARENE UNIVERSITY

My signature below gives the MNU Sports Medicine Staff permission to receive access to any health care information

from other health care providers, including but not limited to each other, team physicians, insurance for the purpose of

treatment, payment, and or for health care operations. This includes, but not limited to, documentation such as office

visit notes, diagnostic test reports, and operation reports.

Please send documents/information to:

Brendon Powers, ATC

2030 E. College Way

Olathe, KS 66062

(F) 913-971-3388

__________________________________ _________________________________ _________________

Print Name Signature of Student-Athlete Date


__________________________________ _________________________________ _________________


MNU ATHLETIC TRAINING 2015/2016

MIDAMERICA NAZARENE UNIVERSITY ATHLETIC INSURANCE

INSURANCE AGREEMENT

Last Name:________________________

First Name:_____________________

Middle Initial:___________

Date of Birth:______________________

SS #____________________________

Sport:__________________

Who is the owner of your primary insurance policy? (PLEASE CIRCLE ONE)

Parent/Guardian OR Self

I have received and understand the attached MidAmerica Nazarene University Athletic Insurance Information. I

attest that I am covered under an excess policy provided by MidAmerica Nazarene University for injuries incurred

at scheduled practices, training, and games. I am submitting the Athlete insurance form and attaching a card or

front and back copy of my primary insurance card(s) which does cover me for athletic injuries/accidents when I

am residing at MidAmerica Nazarene University. I understand that illnesses and other general medical

conditions are not covered under MidAmerica Nazarene University Athletics secondary insurance policy.

I agree that within this academic school year if for any reason the identified primary insurance policy ceases to be

in force I will notify the athletic department as soon as I know coverage is no longer in effect. I understand that I

must have insurance coverage that covers athletic injuries while I reside at MidAmerica Nazarene University to

participate and will be disqualified from practice, training, and games if my coverage is terminated, and required

to purchase a policy through the school if another plan is not already in place.

I agree that in the event that the Excess Policy that MidAmerica Nazarene University has purchased is needed

that I will be responsible for the deductible and any balances not covered after the benefits under the excess

policy have been paid, and any co-pays and from my primary insurance.

*If your parent/guardian is the owner of your primary insurance policy they must sign this agreement before

you will be cleared to participate.

______________________________ ______________________________

Printed name of Student Athlete Printed name of Parent / Guardian

______________________________ ______________________________

Signature of Student Athlete Signature of Parent / Guardian

_______________________ _______________________

Date Date


2015/2016

ACCEPTANCE OF RISK/LIABILITY WAIVER & CONSENT FOR HEALTHCARE A. The undersigned hereby certifies that the answers to the required Health History questionnaire are correct, true, and

honest.

B. Understands that having passed the physical examination does not necessarily mean that he/she is

physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify

him/her.

C. Understands that he/she must refrain from practices or games during medical treatment until he/she is discharged from

treatment by both the Team Physician and the Athletic Trainers. Self release by the athlete will waive the sports

medicine staff from any liability that results during athletic participation and or practice.

D. Understands that the MNU Team Physicians and Athletic Trainers may review this questionnaire, physical examination

and if necessary, any sports injury and illness which may interfere with or affect his/her ability to play.

E. Understands and accepts the risks of injury, permanent disability, and death inherent to their sport. By signing below

he/she pledges to do the best to reduce risks by keeping in the best possible condition, examining assigned protective

equipment daily, following the advice of the Team Physician(s), attending physicians, athletic trainers, and/or coach

concerning the prevention, treatment, and rehabilitation of all athletic injuries.

F. Will promptly notify the sports medicine staff of any changes in his/her health status, including injuries, illnesses

occurring during in season, off season, and summer.

G. I grant permission to the Athletic Training Staff to hospitalize and secure treatment for myself for any athletic injuries or

medical conditions deemed to need immediate treatment by a physician. If the athlete is under the age of 18, the

undersigned parent grants permission to the Sports Medicine Staff to hospitalize and secure treatment for my

son/daughter or ward for any athletic injury or medical condition deemed to need immediate treatment by a physician.

H. Every athlete must have athletic injury/accident insurance effective by his/her report date in August 2015/January

2016, with continuous coverage throughout the calendar year and must provide a front/back copy of their insurance

card. Any insurance lapse without proper notification of the athletic training staff could/will result in removal from

the team roster, immediate loss of all athletic scholarship assistance, and responsibility for all medical bills incurred.

I. My signature below gives the MNU Sports Medicine Staff my permission to release any health care information to other

health care providers, to appropriate persons, including but not limited to each other, team physicians, athletic training

students, my parents, or my athletic coaches either written and/or orally, for the purpose of treatment, payment, and

or for health care operations.

I, the undersigned, have read and understood the preceding medical policy statement and agree to follow its procedures. I

also hereby release MidAmerica Nazarene University, its agents and employees from any liability caused by, or arising out of

the my (or athlete's) participation in the University's' athletic program.

__________________________________ _________________________________ _________________

Print Name Signature of Student-Athlete Date


__________________________________ _________________________________ _________________


MNU paperwork cover NEW 2015-2016.pdf (P)€¦ · Have you had herpes or MRSA skin infection? M23 Do you have frequent changes in your sleeping patterns? M24 Do you have a history

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