Gwynedd-Mercy University Sports Medicine Medical History Form Name ____________________________________________________ Sex _______ Age _____ Date of Birth __________________

Year of Study FR SO JR SR Grad Sport (Student-Athletes only)________________________________________

Home Address ______________________________________________________ Home Phone # ____________________________

Residence Hall_______________________________ RM # ______________ Cell Phone # _________________________________

Family Physician _______________________________________________ Physician Phone # _________________________________

Emergency Contact Name _________________________________ Relationship _______________Phone (H)__________________(W or C)_______________

Medical History: Please explain the “Y” answers in the space below.

1 Do you have a current illness/injury or currently under

a doctor’s care? Y N

8 Do you have any allergies(ex. Pollen, medicines,

food, or insects)? Y N

2 Have you ever been hospitalized? Y N 9 Have you ever been dizzy during or after exercise in

the heat? Y N

Have you ever had surgery? Y N 10 Do you have current skin problems

(ex. itching, rashes, acne, fungus, blisters)? Y N

3 Have you ever passed out during or after exercise? Y N 11 Have you ever become ill from exercising in the heat? Y N

Have you ever had chest pain during or after exercise? Y N 12

Have you ever had problems with your eyes or

vision? Y N

Have you ever had racing of your heart or skipping

heartbeats? Y N

Do you have contacts or glasses?

Please specify: Y N

Have you ever been told you have a heart murmur? Y N 13 Have you ever gotten unexpectedly short of breath

with exercise? Y N

Have you had a serve viral infection (ex. Myocarditis

or Mononucleosis) within the last month? Y N

Do you have asthma? Y N

Has a physician ever denied or restricted your

participation in sports for any heart problems? Y N

Do you have seasonal allergies that require medical

treatment? Y N

4

Have you ever had a head injury or concussion? Y N

14 Do you use any special protective or corrective

equipment or devices that aren’t usually used for your

sport or position? (ex. brace, orthotic)

Y N

Have you ever been knocked out, become unconscious,

or lost your memory? Y N

15 Have you ever had a sprain, strain, or swelling after

an injury? Y N

If yes, how many times? __________________ Have you ever broken or fractured any bones or

dislocated any joints? Y N

When was your last concussion?_______________________ Have you had any other problems with pain or

swelling in muscles tendons, bones, or joints? Y N

How much time was lost from physical activity?

____________________________________

16 Do you want to weigh more or less than you do now? Y N

Have you ever had a seizure? Y N Do you lose weight regularly to meet weight

requirements for your sport? Y N

Do you have frequent or severe headaches? Y N 17 Do you feel stressed out? Y N

Have you ever had numbness or tingling in your arms,

hands, legs, or feet? Y N

Have you ever felt depressed? Y N

Have you ever had a stinger, burner, or pinched nerve? Y N 18 Have you ever been diagnosed with or treated for

sickle cell trait or sickle cell disease? Y N

5 Are you missing any paired organs or ever have an

organ transplant? Y N

19 Female Only

When was your first menstrual period? ___________________

When was your most recent menstrual period? _____________

How much time do you usually have from the start of one

period to the start of another? _________________________

How many periods did you have in the last year? ___________

6 Have you ever been diagnosed with ADD/ADHD by a

physician? (NCAA mandates documentation of prescribed

medications, See Attached Form) Y N

7 Are you currently taking any prescription or non-

prescription medication or using an inhaler? Y N

Please explain any yes answers:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Gwynedd-Mercy University Sports Medicine Physical Exam

Medical Evaluation Name: ____________________________________________ DOB:________________________________

Vital Signs:

Ht. ___________ Wt. ______________ BP: _____________ Pulse: ___________

Vision: Right: 20/____ Left: 20/____ Corrected: Y N Pupils: Equal Unequal

Medical Findings

Appearance Normal Abnormal Comment: ____________________________________

Eyes/Ears/Nose Normal Abnormal Comment: ____________________________________

Lymph Nodes Normal Abnormal Comment: ____________________________________

Pulses Normal Abnormal Comment: ____________________________________

Heart/Lungs Normal Abnormal Comment: ____________________________________

Abdomen Normal Abnormal Comment: ____________________________________

Genitalia (Males) Normal Abnormal Comment: ____________________________________

Skin Normal Abnormal Comment: ____________________________________

Clearance Level:

Cleared Not Cleared (Reason) _______________________________________________________

Cleared after Evaluation/Rehabilitation for the following:

Recommendations/Limitations:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

___________________________________________________________________________

Physician’s Signature: __________________________________________ Date: ________________

PHYSICIAN’S STAMP:

I hereby give permission to the Student Health Center practitioners or to a physician of their choice, to prescribe

necessary medication and/or perform treatments or operations necessary in the best interest of my health. Moreover, I

understand that it is the policy of the Gwynedd Mercy Healthcare community to notify my parents or guardians of any

serious illness or injury.

_________________________________________ ____________________________________________ Signature of Student Date Signature of Parent/Guardian Date

(if student is a minor)

Gwynedd-Mercy UniversitySports Medicine Physical Exam

Musculoskeletal Evaluation

Name: _____________________________

Musculoskeletal Findings

Neck/Back Normal Abnormal Comments: ____________________________

Rt. Shoulder/Arm Normal Abnormal Comments: ____________________________

Lt. Shoulder/Arm Normal Abnormal Comments: ____________________________

Rt. Elbow/Forearm Normal Abnormal Comments: ____________________________

Lt. Elbow/Forearm Normal Abnormal Comments: ____________________________

Rt. Wrist/Hand Normal Abnormal Comments: ____________________________

Lt. Wrist/Hand Normal Abnormal Comments: ____________________________

Rt. Hip/Thigh Normal Abnormal Comments: ____________________________

Lt. Hip/Thigh Normal Abnormal Comments: ____________________________

Rt. Knee Normal Abnormal Comments: ____________________________

Lt. Knee Normal Abnormal Comments: ____________________________

Rt. Foot/Ankle Normal Abnormal Comments: ____________________________

Lt. Foot/Ankle Normal Abnormal Comments: ____________________________

Clearance Level:

Cleared Not Cleared (Reason): __________________________________

Cleared after Evaluation/Rehabilitation for the following:

Recommendations/Limitations:

Physician’s Signature: _____________________________________________ Date: ________________

Gwynedd-Mercy University Sports Medicine ADHD Medical Exemption Form

Please have this form completed by your physician and return with your Athletic Training paperwork prior to the start of your

athletic season. Criteria on the form must be completed for NCAA medical exemption status for any athletic taking ADHD/ADD

medications. Without medical exemption the athlete will test positive when drug tested by Gwynedd Mercy University and/or the

NCAA. We appreciate your cooperation in this documentation process.

Required Evaluation Components:

Student-Athlete Name: ________________________________ Date of Birth:____________________

Physician Name (printed) and Specialty: __________________________________________________

Physician Office Address:_______________________________________________________________

City/State: ____________________________________________________ Zip:___________________

Physician Phone: _____________________________ Date of Clinical Evaluation: ________________

BP: ______ / ______ HR: ______

Diagnosis:____________________________________________________________________________

_____________________________________________________________________________________

Alternative Non-Banned Substances have been considered? YES NO

Comments: __________________________________________________________________________

_____________________________________________________________________________________

Medication(s) and Dosage: _____________________________________________________________

Follow-Up Orders:____________________________________________________________________

_____________________________________________________________________________________

Evaluation Components (if available):

Reported ADHD symptoms: ____________________________________________________________

_____________________________________________________________________________________

Psychological Testing Results: __________________________________________________________

_____________________________________________________________________________________

Laboratory/Testing Results: ____________________________________________________________

_____________________________________________________________________________________

Summary of Previous ADHD Diagnosis: __________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Attachments MUST Include: Please attach ADHD rating scale (e.g. Conners, ASRS, CAARS),

scores, and report summary. Supporting documentation of the comprehensive clinical evaluation

(referencing DSM-IV criteria), and a copy of the most recent prescriptions.

Gwynedd Mercy University Sports Medicine Student-Athlete Information Form

Name:_________________________________________ Sport:___________________________

Date of Birth:_________________ SSN:_________________________ Year:______________

Home Address: _________________________________________________________________________

City/State/Zip: __________________________________________________________________________

Home Phone: _________________________________ Cell Phone: _______________________________

EMERGENCY CONTACT:

Parent/Guardian Name(s):___________________________________________________________

Home Address: ____________________________________________________________________

City/State/Zip:_____________________________________________________________________

Home Phone:______________________________

Cell Phone:________________________________ Work Phone:____________________________

Cell Phone:________________________________ Work Phone:____________________________

Primary Care Physician: ____________________________________________________________

Address:__________________________________________________________________________

Office Phone:________________________________ Office Fax:___________________________

Insurance Company:________________________________________________________________

Address:__________________________________________________________________________

Member Services Phone:_________________________________

ID/Policy #:___________________________________Group #: ____________________________

Insurance Policy Holder Name:_________________________________________

Relationship to Athlete: __________________________________

Policy Holder Address:______________________________________________________________

Policy Holder Primary Phone:______________________________

Policy Holder’s Employer’s Address:____________________________________________________

Policy Holder’s Employer’s Primary Phone:______________________________

Is the policy an HMO, PPO, or POS? ________________________

*ATTACH A CLEAR COPY OF BOTH SIDES OF CURRENT INSURANCE CARD*

FRONT BACK

Gwynedd-Mercy University Sports Medicine

HIPAA/FERPA Authorization to Release Medical Information

Name:____________________________ Sport(s):_______________________

Print Name Print Sport(s)

The Health Information Portability & Accountability Act (HIPAA) of 1996 & the Family Educational Rights &

Privacy Act of 1974 (FERPA/Buckley Amendment) requires the protection of your personal health information.

You have a right to confidential treatment of all information contained in medical records pertaining to your care

while at Gwynedd-Mercy University. You also have to right to be notified of the presence of any individual during

treatment of any injuries &/or illnesses (physical, mental, &/or emotional) during the course of your medical care.

If you sustain an injury or illness that directly affects your participation in Intercollegiate Athletics at

Gwynedd-Mercy University, it is important to understand that the Athletic Training Staff may need to

discuss this injury or illness with members of the Campus Health &/or Counseling Services Departments, as

well as coaches & pertinent Athletics Staff. Only minimally necessary information will be released and

discussed.

By signing this document, I authorize members of the Gwynedd-Mercy University Athletic Training staff,

Coaching/Athletic Department Staff, Physicians, Campus Health Department professional staff, & Counseling

Services professional staff to discuss only pertinent aspects of any injuries/illness that I may sustain that will

directly affect my ability to participate in Intercollegiate Athletics.

The reason for this disclosure is to advise my Coaching staff/Athletic Department staff (via Athletic Training Staff)

about any diagnosis or treatment concerning my medical condition so that they may make decisions regarding my

ability to participate in Intercollegiate Athletics.

I understand that at any time I may revoke this authorization by notifying the Head Athletic Trainer in writing. I

also understand that I may inspect & receive a copy of any information used under this authorization. I may also

refuse to sign this authorization & that refusal to sign will in no means affect my eligibility to participate in

Intercollegiate Athletics at Gwynedd-Mercy University or obtain treatment for any injuries/illnesses. This

authorization will remain in effect for a period of six years.

□ I consent to this authorization

□ I refuse consent to this authorization

Signature of Student-Athlete_____________________________________ Date____________

Signature of Parent/Guardian_____________________________________ Date____________ (if student-athlete is under 18 years of age)

Gwynedd-Mercy University Sports Medicine

Acknowledgement & Waiver of Risk/Liability

I, ____________________________________, hereby release Gwynedd-Mercy University and its officers, agents, and

employees, including but not limited to Athletic Training Staff, Coaches, & Administration, from any and all liability and

responsibility in the event that I become injured in any way during my participation in Intercollegiate Athletics.

I hereby acknowledge the risks that participating in Intercollegiate Athletics at Gwynedd-Mercy University may result in

injury, including, but not limited to: death, neck/spinal injuries, injuries to bones, joints, & muscles, and any injury that may

affect future ability to earn a living, engage in other business, social, or recreational activities. I certify that I have had a Pre-

Participation Medical Exam (by a licensed physician or certified registered nurse practitioner) and am in good health to

participate in Intercollegiate Athletics. I certify that I have no known physical conditions that could impair my activity or

worsen my condition unless stated below:

I hereby acknowledge that the Gwynedd-Mercy University Athletic Training Staff (and its agents) may deny/restrict my

participation in Intercollegiate Athletics due to an injury or medical condition. I agree to follow and obey all medical

orders/advice given to me by the Gwynedd-Mercy University Athletic Training Staff (and its agents). In addition, all costs

incurred for medical expenses resulting from an injury in Intercollegiate Athletics will be forwarded to my personal health

insurance. Any excess costs, will then be considered by the Secondary Insurance Agent contracted by Gwynedd-Mercy

University.

I hereby acknowledge that by signing this waiver, I have read it and fully comprehend it.

_________________________________________________ ______________________

Signature of Student Athlete Date

_________________________________________________ ______________________

Signature of Parent/Guardian (if under 18) Date

Acknowledgement of Insurance Requirements

I, ____________________________________________, as parent, guardian, legal representative, or self, attest that

________________________________ has insurance coverage under a current, in-force insurance policy for all injuries that

occur while he/she is participating in intercollegiate athletics at Gwynedd-Mercy University.

If there is a material change in coverage or expiration of coverage, I agree to notify Gwynedd-Mercy University

Athletic Department of this development and update the insurance information I have on file with Gwynedd-Mercy University

immediately.

I understand and agree that Gwynedd-Mercy University will assume no responsibility whatsoever for the payment of,

or authorization to pay, medical expenses resulting in injuries that occur while participating in intercollegiate athletics at

Gwynedd-Mercy University.

_________________________________________________ ______________________

Signature of Student Athlete Date

_________________________________________________ ______________________

Signature of Parent/Guardian (if under 18) Date

(name, please print)

(student-athlete name)

Gwynedd-Mercy University Sports Medicine

Sickle Cell Trait Form for NCAA Intercollegiate Athletics

About Sickle Cell Trait Sickle cell trait is not a disease. Sickle cell trait is an inherited condition affecting the oxygen-carrying substance,

hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like

a disease.

Sickle cell trait is a common condition (> three million Americans)

Although Sickle cell trait occurs most commonly in African-Americans and those of Mediterranean, Middle Eastern,

Indian, Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this

condition.

Those with sickle cell trait usually have no symptoms or any significant health problems. However, sometimes during very

intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in those

with sickle cell trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden collapse

and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3

continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning

training. Extreme heat and dehydration increase the risks. (NCAA: A Fact Sheet for Coaches, Sickle Cell Trait,

http://web1.ncaa.org/web_files/health_safety/SickleCellTraitforCoaches.pdf)

More information and resources regarding sickle cell trait and the NCAA’s recommendation for sickle cell trait testing can

be found at the NCAA web site resource pages regarding the sickle cell trait, accessible at: www.NCAA.org/health‐safety.

Sickle Cell Trait Testing The NCAA recommends that all student-athletes have knowledge of their sickle cell trait status. Student-athletes must 1)

show proof of a prior test with results; 2) have a blood test to check for sickle cell trait; or 3) sign a testing waiver

declining options 1 and 2. Whichever option is chosen, it must be completed before the athlete participates in any

intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc.

Athletes who are positive for the trait will be allowed to participate in intercollegiate athletics; this does NOT prohibit you

from playing.

One of the following options must be chosen. Include any documentation if necessary:

1.) Copy of athlete’s newborn sickle cell testing result attached. ________ Date: ____________

Most states require testing at birth, check with your hospital or pediatrician

2.) Copy of recent sickle cell screening test result attached. ________ Date: ____________

Cost of testing is the responsibility of the athlete

3.) SICKLE CELL TESTING WAIVER: By signing this waiver I understand and acknowledge that the NCAA recommends that all student-athletes

have knowledge of their sickle cell trait status. Additionally, I certify that I have read and fully understand the

aforementioned facts and I have had the opportunity to review the NCAA website for further information about

sickle cell trait and sickle cell trait testing.

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 and/or knowledge of sickle cell trait status to the

Gwynedd-Mercy University Athletic Department.

I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify and

hold harmless Gwynedd-Mercy University, its officers, employees, agents and their successors and assigns from

any and all costs, claims, damages or expenses, including attorneys fees, arising from any loss or personal injury

that might result from my refusal to be tested.

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’s Signature Student-Athlete’s Print Name Date SPORT(s):

______________________________ ___________________________ ______

Parent/Guardian’s Signature (if under 18 years of age) Parent/Guardian’s Print Name Date

Gwynedd-Mercy University Sports Medicine

Student-Athlete Concussion Statement

☐ I understand that 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.

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

Initial or athletic trainer.

________ A concussion can affect my ability to perform everyday activities, and affect reaction

Initial time,balance, sleep, and classroom performance.

________ You cannot see a concussion, but you might notice some of the symptoms right away.

Initial 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

Initial 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

Initial that results in concussion-related symptoms.

________ Following concussion the brain needs time to heal. You are much more likely to have a

Initial repeat concussion if you return to play before your symptoms resolve.

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

Initial

_____________________________________________ ___________________

Signature of Student-Athlete Date

_____________________________________________

Printed name of Student-Athlete