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					UNIVERSITY
HEALTH SERVICE


CCSU
Central Connecticut State University


    Welcome Varsity Athlete,

    The NCAA mandates a medical evaluation within six months prior to participation in any practice, competition
    or out-of-season conditioning activities. In order for you to participate in our Varsity Athletic Program, we
    require the completion of the Connecticut State University System’s Confidential Health Form and the Athletic
    Pre-Participation Examination Form. For most students, the Athletic Pre-Participation Examination is scheduled
    in our office during June and July and lasts about 1 hour. For those of you who live farther than 1 hour from
    campus or were admitted mid-year, we will make other arrangements. All forms can be found at
    www.ccsu.edu/health under the Health Service Forms tab.

    Confidential Health Form Requirements

          This form must be submitted as soon as possible. We must have it on file before your Pre-Participation
           Examination visit.
          We ask that you or your physician submit any additional information regarding any cardiac evaluation
           (echocardiogram, EKG, etc) or orthopedic evaluations (surgery, physical therapy) along with your
           medical form.
          The more information we have before you come to your pre-participation visit, the more easily we can
           evaluate you for clearance to play on the Varsity team.

    Pre-participation Examination Visit

          This appointment is focused on medical areas of concern to ensure the safety of each athlete in their
           field of play. We recognize this visit may seem redundant, however, our goal is to take every precaution
           in ensuring the safety of our athletes.
          This is done by the University medical staff and is free.
          It will be scheduled only after a complete Confidential Health Form is submitted to Health Service.
          If we require any additional medical evaluations or information we feel necessary prior to the start of
           preseason, we will inform you at the time of your visit what this will entail.
          This form can be completed by your primary care provider (PCP) if you live greater than one hour from
           campus. However, after reviewing the form, we may still require an examination at University Health
           Services prior to participation. Please call us if this applies to you before scheduling an appointment
           with your PCP.

    All of the above must be completed in order to be cleared medically for your sport. Please remember to have
    an appropriate evaluation within six months prior to participation in any practice, competition or out-of-season
    conditioning activities. Please contact us at 860-832-1925 if you have questions or require special
    considerations.


    Wishing you a healthy, successful, and safe varsity season,

    Christopher Diamond, MD
    Director, University Health Services


        1615 Stanley Street – New Britain, Connecticut 06050-4010 – Phone: 860.832.1925 – Fax: 860.832.2579 – www.ccsu.edu/health
PLEASE RETURN TO THE APPROPRIATE UNIVERSITY HEALTH SERVICE
Central Connecticut State                Eastern Connecticut State              Southern Connecticut State                Western Connecticut State
University                               University                             University                                University
University Health Service                University Health Service              University Health Service                 University Health Service
1615 Stanley Street                      185 Birch Street                       501 Crescent Street                       181White Street
New Britain, CT 06050                    Willimantic, CT 06226                  New Haven, CT 06515                       Danbury, CT 06810
860/832-1925 Fax 860/832-2579            860/465-5263 Fax 860/465-4560          203/392-6300 Fax 203/392-6301             203/837-8594 Fax 203/ 837-8583



                                   Connecticut State University Health Service
                                           Confidential Health Form
State of Connecticut General Statute regulations requires all full and part-time matriculated students,
born after December 31, 1956, to provide proof of adequate immunization against measles (rubeola),
German measles (rubella), chicken pox (varicella), and mumps before permitting such students to enroll.
See attached guidelines for full details.

PLEASE RETAIN A COPY OF THIS FORM

Entering semester:          Fall         Spring       year: 20 _____

PART A
LAST NAME                                         FIRST NAME                                               STUDENT ID NUMBER


BIRTH DATE                                          BIRTH PLACE                                            HOME PHONE
       _______/_______/_______                                                                             (______) _______-___________
PERMANENT HOME ADDRESS                                                                                    STUDENT CELL PHONE
STREET                                                                           APT:                      (______) _______-___________
                                                                                                         ____________________________________
CITY     ________________________________              STATE ____________         ZIP    ___________
                                                                                                           SEX:     MALE        FEMALE
PARENT, GUARDIAN OR SPOUSE                 LAST NAME                                     FIRST NAME                           PHONE
CONTACT INFORMATION (CIRCLE ONE)
 STREET ADDRESS (IF DIFFERS FROM ABOVE)                                  CITY, STATE AND ZIPCODE



PART B: IMMUNIZATION HISTORY

DTP, TD OR TDAP:     (ADULT) BOOSTER _____/_____/_____                    POLIO SERIES
CIRCLE ONE              (UPDATED WITHIN PAST 10 YEARS)
                                                                          1ST____/____/____ 2ND____/____/____ 3 RD____/____/____


MMR # 1 AND # 2 OR LAB             MMR   #1 DATE _____ /_____/_____        #2 DATE _____ /______/______ OR
CONFIRMED IMMUNITY OR
                                   ATTACH LAB RESULT TO THIS FORM SHOWING IMMUNITY TO MEASLES, RUBELLA AND MUMPS OR
CERTIFICATE OF DISEASE
                                   ATTACH CERTIFICATE OF DISEASE FROM PHYSICIAN OR HEALTH DEPARTMENT FOR MEASLES, MUMPS AND RUBELLA

MENINGOCOCCAL VACCINE
(“MENINGITIS” VACCINE)             DATE _____ /_____/_____       REQUIRED FOR ALL RESIDENCE HALL STUDENTS


HEPATITIS B SERIES
(highly recommended)               1ST _____ /_____/_____         2ND _____ /_____/_____        3RD _____ /_____/_____


HUMAN PAPILLOMA VACCINE
                                   #1 ______/______/_______       #2 ______/_______/_______     #3_______/______/______


VARICELLA VACCINE OR LAB           VACCINE DATES: #1 ____/____/____      #2 ____/____/____ OR
CONFIRMED IMMUNITY OR
                                   ATTACH LAB RESULT SHOWING IMMUNE STATUS OR
CERTIFICATE OF DISEASE
                                   ATTACH CERTIFICATE OF DISEASE FROM PHYSICIAN OR HEALTH DEPARTMENT
PART C: HEALTH HISTORY (MUST BE COMPLETED)
If you have had any of the following, please check „yes‟.      Explain YES answers in the space provided.
                            Yes                                Yes                                      Yes                                  Yes                                Yes
SKIN                              RESPIRATORY                         GENITOURINARY                            MUSCULOSKELETAL                     ENDOCRINE
MRSA/boils                         Asthma                              Urinary Tract Infections                 Arthritis                           Diabetes
 Other Skin Problems               Chronic Cough                       Kidney Stones or Disease                 Fractures or Dislocations           Sudden Weight Change
EYES                               Bronchitis or Pneumonia            Sexually Transmitted Infection            Back/ Disc Problems                 Weight issues
 Blindness                         Do you smoke?                      Women:                                    Scoliosis                           Thyroid Problems/Disease
 Eye Injury/Disease               CARDIAC                              Menstrual Irregularity                   Disease of the Joints              HEMATOLOGIC
 Wears Contacts/Glasses            High Blood Pressure                 Severe Cramps                            Paralysis                           Easy Bruising
 Color Blindness                   High Cholesterol                    Abnormal Pap Smear                      NEUROLOGICAL                         Anemia/ low iron
EARS/NOSE/THROAT                   Irregular Heart Rate                PMS                                      Migraines                           Sickle Cell Trait/Disease
 Hearing Loss/ Deafness            Heart Murmur                        Breast Problems                          Frequent Headaches                  Clotting Disorder
 Frequent Ear Infections           History of Palpitations             Breast Surgery                           Concussion                         INFECTIOUS DISEASE
 Perforated Eardrum                Chest Pain                         Pelvic Inflammatory Disease               Severe Head Injury                 Staph infection
 Repeated Nosebleeds              GASTROINTESTINAL                     Gyn Surgery                              Dizziness/Fainting                  Mononucleosis
 Sinus Infections                  Stomach Problems/ Ulcer            Men:                                      Insomnia                           HIV
                                   Requires Special Diet               Epididymitis                             Neuromuscular Disorder              Malaria
 Tonsils/Adenoids Surgery          Hepatitis                           Testicular Torsion                       Seizures/Epilepsy                   Meningitis
DENTAL                             Gallbladder Problems                Loss/Damaged Testicle                   MENTAL HEALTH                        HIV/AIDS
 Bleeding Gums                     Irritable Bowel Problems            Undescended Testicle                     Anxiety/Depression                  HOSPITALIZATIONS
 Poor teeth                        Hemorrhoid Problems                 Testicular Cancer                        Attention Deficit Disorder           List dates:
Wisdom Teeth Extraction            Appendectomy                                                                 Anorexia and/or Bulimia             SURGERY
                                   Hernia                                                                       Suicide Attempt

DESCRIBE details for each „yes‟ with dates. Please use an extra page if space is not adequate
___________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________


  CURRENT MEDICATIONS                                                                    ALLERGIES:         No known drug allergies.
                                                                                                       List allergy and describe reaction that occurs
  NAME                                DOSAGE AND DOSING SCHEDULE
  _______________________             __________________________________                 Medication Allergy: _________________________________________________
  _______________________             __________________________________                 Environmental/ Seasonal Allergy: ______________________________________
  _______________________             __________________________________                 Insect or Bee Allergy: ________________________________________________
  _______________________             __________________________________                 Food Allergy: ______________________________________________________


FAMILY HISTORY: If you are adopted or do not know your family history check here:

Has any member of your immediate family had any of the following?

Anemia/Blood Disorder/Sickle Cell Disease_____ Cardiovascular Disease (Heart Attack or Stroke)_____ High Blood Pressure_____ Cancer _____

Addiction or Mental Illness_____ Tuberculosis_____ Diabetes_____ Kidney Disease_____ Asthma/Allergies_____ Thyroid Disease_____

Other relevant family history: _____________________________________________________________________________________________________


SIGNATURE(S) REQUIRED:
I hereby authorize the staff of a Connecticut State University System Health Service to provide medical treatment and services to me as they deem
appropriate. This authorization will remain in effect as long as I am a student in the CSU System. In the case of a minor (under 18) a parent or legal
guardian‟s signature below permits the student to obtain health care in the absence of the guardian.


             STUDENT NAME (PLEASE PRINT) ______________________________________________________________

             STUDENT SIGNATURE:              _____________________________________________________ DATE _____/______/______


CONSENT FOR MINOR (UNDER 18 YEARS OF AGE): I give my permission for medical treatment for my daughter/son if accident/illness should occur
while she/he is a student at a Connecticut State University System campus. This would include referral to a local hospital which may result in
her/his hospitalization, anesthesia, and surgery should it be necessary and I am unable to be reached.


             PARENT/ GUARDIAN‟S NAME (PLEASE PRINT) ___________________________________________ RELATIONSHIP _____________

             SIGNATURE OF PARENT/GUARDIAN: __________________________________________________ DATE _____/______/______
                                                                                  STUDENT NAME: _________________________________________ (PRINT)
PART D: TUBERCULOSIS (TB) RISK ASSESSMENT:
SECTION I: TO BE FILLED OUT BY THE STUDENT; SECTION II: TO BE FILLED OUT BY THE HEALTH CARE PROVIDER.

SECTION I: Student to answer the following questions:
                                                                                                              YES      NO
 1. To the best of your knowledge, have you ever had close contact with anyone who was
    sick with tuberculosis (TB)?
 2. Were you born in one of the countries listed below?
 3. Have you traveled or lived for more than one month in one or more of the
    countries listed below?
 4. Do you have Diabetes, Kidney Disease, Immune System Diseases, including HIV/AIDS,
    Silicosis, chronic steroid therapy or a history of the following: substance abuse, cancer,
    pulmonary fibrotic lesions on x-ray, Gastrectomy, Jejunoileal bypass surgery?
 5. Have you ever had a positive tuberculosis skin test in the United States?

 COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB) World Health Organization, Global Tuberculosis control.           WHO report 2008
 Afghanistan, Algeria, Angola, Anguilla, Argentina, Armenia, Azerbaijan, Bahamas, Bahrain, Bangladesh, Belarus, Belize, Benin, Bhutan, Bolivia, Bosnia &
 Herzegovina, Botswana, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad,
 China, Columbia, Comoros, Congo, Congo DR, Cote d’Ivoire, Croatia, Djibouti, Dominican Republic, Ecuador, Egypt, El Salvador, Equatorial Guinea,
 Eritrea, Estonia, Ethiopia, Fiji, French Polynesia, Gabon, Gambia, Georgia, Ghana, Guam, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras,
 India, Indonesia, Iran, Iraq, Japan, Kazakhstan, Kenya, Kiribati, Korea-DPR, Korea-Rep, Kuwait, Kyrgyzstan, Lao PDR, Latvia, Lesotho, Liberia,
 Lithuania, Macedonia-TFYR, Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia, Moldova-Rep,
 Mongolia, Montenegro, Morocco, Mozambique, Myanmar, Namibia, Nauru, Nepal, New Caledonia, Nicaragua, Niger, Nigeria, Niue, Northern Mariana
 Islands, Pakistan, Palau, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Qatar, Romania, Russian Federation, Rwanda, St.
 Vincent & the Grenadines, Sao Tome & Principe, Saudi Arabia, Senegal, Seychelles, Sierra Leone, Singapore, Solomon Islands, Somalia, South Africa, Spain,
 Sri Lanka, Sudan, Suriname, Syrian Arab Republic, Swaziland Tajikistan, Tanzania-UR, Thailand, Timor-Leste, Togo, Tokelau, Tonga, Tunisia, Turkey,
 Turkmenistan, Tuvalu, Uganda, Ukraine, Uruguay, Uzbekistan, Vanuatu, Venezuela, Vietnam, Wallis & Futuna Islands, West Bank & Gaza Strip, Yemen,
 Zambia, Zimbabwe


 ____________________________________________________________________________________________________
 SECTION II: TO BE FILLED OUT BY THE HEALTH CARE PROVIDER Tuberculosis (TB) Testing Evaluation:
 • IF THE ANSWER IS YES to questions 1-5 above, the CSU System requires that a healthcare provider complete the TB testing evaluation below
           within 6 months prior to the start of classes. If the PPD skin test is positive or has been positive in the past a chest x-ray is required and
           must be done within 6 months prior to the start of classes.

 NOTE: Previous BCG vaccine does not exempt the student from this requirement and a chest x-ray is not an acceptable substitute for a
           PPD (MANTOUX Skin Test).

 FOR INTERNATIONAL STUDENTS – TUBERCULIN SKIN TESTING MUST BE DONE IN OUR UNIVERSITY HEALTH
 OFFICE or ANOTHER UNITED STATES MEDICAL FACILITY.

 Tuberculin Skin Test: Use 5TU Mantoux test or IGRA(Quantiferon-TB). Tine is not accepted.
 Date Planted:    RESULT: (after 48-72 hours): _____ mm induration
 ___/____/____    If no induration, please put “0” mm
                       INTERPRETATION: _____ POSITIVE _____ NEGATIVE
                       Read by: ___________________ (signature)
 Date
 ___/____/____         IGRA (QFT-G or QFT-GIT)            _____POSITIVE ____ NEGATIVE


 IF TB SKIN TEST POSITIVE- (currently or in the past) A CHEST X-Ray is required

 Chest x-ray: __Normal         __Abnormal – please describe                      Date of x-ray:

 Treatment: No         ____
            Yes        __________________________________________________________
                                  (drug, dose, frequency, dates, location)
PART E: This page to be completed by the student’s HEALTH CARE PROVIDER.
  PHYSICAL EXAMINATIONS PERFORMED WITHIN ONE YEAR OF ENROLLMENT WILL BE ACCEPTED

STUDENT NAME: ______________________________________________________ DATE OF BIRTH: _____________________
                                  NAME OF STUDENT (PRINT)

WGT. _______        HT. _______         BP __________          P ______

VISION:     RIGHT 20/ _______________ LEFT 20/ ________________          WITH GLASSES: RIGHT 20/ _____________ LEFT 20/ ______________

HEARING: RIGHT ___________________ LEFT ___________________               METHOD USED ______________


            SYSTEM                  NORMAL                            DESCRIBE IF ABNORMAL                                If clinically indicated from history
                                                                                                                            or physical exam; required for
                                                                                                                                 Division I athletes only

GENERAL APPEARANCE                                                                                                       DATE

SKIN                                                                                                                     URINALYSIS

HEENT                                                                                                                           SP. GR:

NECK, THYROID                                                                                                                 Glucose:

CHEST, BREASTS                                                                                                                  Protein:

LUNGS                                                                                                                           Micro:

HEART                                                                                                                    DATE :

ABDOMEN                                                                                                                  HGB/HCT

GENITOURINARY

MUSCULOSKELETAL

LYMPHATIC

NEUROLOGICAL

PSYCHOLOGICAL




TUBERCULOSIS SCREENING: PLEASE SEE PART “D” SECTION II FOR SCREENING GUIDELINES.

LIST ALL ALLERGIES (INCLUDING MEDICATIONS, INSECT VENOM, ETC.) _____________________________________________________________________

COMMENT ON TYPE OF REACTION (I.E. RASH, URTICARIA, ANAPHYLAXIS) _____________________________________________________________________

LIST ALL MEDICATIONS CURRENTLY BEING TAKEN _____________________________________________________________________________________

                                                 _____________________________________________________________________________________

COMMENT ON SPECIAL DIETARY REQUIREMENTS _________________________________________________________________________________________

STATUS OF STUDENT‟S PHYSICAL RESTRICTIONS        UNRESTRICTED         PARTIAL RESTRICTION          FULL RESTRICTION

COMMENT _____________________________________________________________________________________________

STATUS OF STUDENT‟S HEALTH             EXCELLENT           GOOD                  POOR            COMMENT ___________________________________

I HAVE REVIEWED AND COMPLETED THE TUBERCULOSIS SCREEINING SECTION OF THIS FORM. I CONFIRM THE IMMUNIZATIONS LISTED IN PART B.

PRINT: HEALTH PROVIDER‟S NAME_________________________________________________________TELEPHONE# (______ ) _______-_________

        ADDRESS ________________________________________________ ________________________ _____________________ ________________
                  STREET                                                       CITY                             STATE              ZIP


HEALTH PROVIDER‟S SIGNATURE________________________________________________________________________ DATE OF EXAM_______________

                                           (This medical certificate will be on file in the University Health Service)
Connecticut State University Immunization Requirements
State of Connecticut General Statutes regulations requires all full and part-time matriculated students born after
December 31, 1956, to provide proof of adequate immunization against measles (rubeola), German measles
(rubella), chicken pox (varicella), and mumps.

                                The following are required for ALL students:

Proof of immunity to Measles (Rubeola): you must provide proof of one of the following:
   Two measles or two MMR immunizations (one after your 1st birthday and one at least one month later)
            1st dose of measles must be given on or after 12 months of age and after January 1, 1969
            2nd dose must be after January 1, 1980 OR
   Documentation (actual lab result) of positive titer (blood test)

Proof of immunity to Rubella: you must provide proof of one the following:
   Rubella vaccination after 1st birthday OR
   Documentation (actual lab result) of positive titer (blood test)

Proof of immunity to Varicella (chicken pox) will be required for all incoming students
beginning August 1, 2010:
   Two varicella immunizations, OR
   Documentation (actual lab results) of positive varicella titer (blood test)

Proof of immunity to Mumps, will be required for all incoming students
beginning August 1, 2010:
   Two mumps immunizations, OR
   Two MMR vaccinations OR
   Documentation (actual lab results) of positive titre (blood work)

Certification of confirmed cases of measles, mumps, rubella & varicella by a licensed health care provider may
be submitted in lieu of the above.

Proof of Meningococcal vaccination (Menactra) is required for all residential students prior to room
assignment. No student may move into campus housing without proof of this vaccine. It is strongly
recommended that all students be vaccinated against this disease.

Hepatitis B: The American College Health Association, the Connecticut Public Health Department, and the
Centers for Disease Control recommend students be immunized against Hepatitis B (this is not required).

IMMUNIZATION EXEMPTIONS

    Students born prior to January 1, 1957 are exempt by age from the measles, mumps, rubella & varicella
     requirement.

    The University will only permit vaccination waivers for religious or medical reasons.
        Exemptions for either medical or religious reasons subjects the individual to exclusion from
        campus in the event of an outbreak of a disease for which immunizations are required.
                Exemption waiver form is available for download

    Online learners do not need to meet the immunization requirement
                  ATHLETIC PRE-PARTICIPATION EXAMINATION
     (To be completed by CCSU University Health Services unless otherwise approved)
Name: _________________________                  Sport: ________________________
SS#:   _______/________/___ ___                  Date of Examination: ___________

PRESENT MEDICATIONS:          __________________________________________________
                                         (list medication and for what purpose)
ALLERGY:     Food, drugs, animals or environmental- _________________________________
                                                  (please note type of reaction, if known. )
            How treated?: (if i.e. hymenoptera, whether a EPIPEN is required)_____________________

NEUROLOGICAL HISTORY:            Hx of the following:
__ Concussion                                   ___ Fainting spell                IN ANY EXTREMITY:
__ Loss of consciousness                        ___ Dizziness                     __ numbness
__ Head injury                                  __ Seizures                       __ stinger/ burner
                                                                                  __ weakness or tingling
If any of the answers are yes, please explain in detail:
_________________________________________________________________________
_________________________________________________________________________
CARDIAC HISTORY:
Has anyone in your family been diagnosed with a heart problem before the age of 50?            _______
Has anyone in your family died before the age of 50 of unknown causes?                         _______
Have you ever been told you have a heart murmur?                                               _______
Have you ever been told you have an irregular heartbeat?                                       _______
Have you ever had any chest palpitations?                                                      _______
Have you ever been told you have something wrong with your heart but you will grow out of it? _______
Have you ever had chest pain during or after exercise?                                         _______
Passing out/___ Dizziness (during or after exercise)                                           _______

Disorders at risk for sudden death - Answer Yes or No
   A. Hypertrophic Cardiomyopathy                                                                        _______
   B. Marfan's and Related Disorders
       (for men a height of 6'2" or greater and women a height of 5'10" or greater)                      _______
   C. Coronary Artery Disease                                                                            _______
   D. Valvular Heart Disease                                                                             _______
   If YES to ANY of the above, please explain below
   __________________________________________________________________________
   __________________________________________________________________________

ASTHMA HISTORY:
1. Have you ever been told you have asthma?
    If yes: At what age was this diagnosed? _________
            Hospital Admissions for asthma: (please explain)____________________________________
                                                              _____________________________________
2. Exercise Induced Asthma? _______
   If yes: When dx: _________________________________
3. Have you ever heard a wheeze whether during exercise or inactivity?                           _________
   Had shortness of breath that was out of the ordinary during or after exercise?                _________
4. Do you notice that you cough after exercise? Yes ___/No ____
5. Medications: Bronchodialator: i.e. Ventolin , Proventil , Maxair, Salbutamol (circle and note frequency )
                  ______________________________________________________
                 Topical Steroid Inhaler: i.e. Vanceril, Azmacort, Aerobid ___________________
                 Cromolyn Sodium Medication i.e. Intal ___________________
6. Seasonal Allergy symptoms and Medications for Allergic Rhinitis:
   nasal congestion/itchy eyes/ rhinitis ______________________________
                               (note which season or change of season is pt. symptomatic)
FEMALE SUPPLEMENTAL MEDICAL HISTORY:
Menarche: _____                 LMP (Date) ___/___
Menses: q _____ d X ______ days G _____ P ______ AB ____
   Have you ever lost your period for any length of time?(more than 3 mos).____________

      Use of Contraceptive: Name __________________

           o   When first started: _______For what reason _____________

      Most recent Pap smear? ________________             Results: __________________

      Do you have menstrual irregularity ?__________ dysmenorrhea _______

      What medication do you use for your cramps? ________________ Do you use tampons? ____

Have you ever been treated for anemia? ______

DIET HISTORY:
Are there certain food groups you refuse to eat? (meats, breads)____
Are you taking any supplements such as multivitamins, calcium, or iron? ____

What is your present weight?                _____
Are you happy with your present weight?     _____
  If not: What would you like to weigh?     _____
          Does your weight affect the way you think about yourself? _____

Have you ever been on a diet? _____
  If yes: How many diets have you been on In the past year? ___
         Have you ever tried to control you weight by
               vomiting? __    laxatives? ___        diuretics? ____         diet pills? ____

  Have you ever been diagnosed as having an eating disorder?(Anorexia N., Bulimia N or both )__________

MUSCULOSKELETAL HISTORY:
Have you had an injury that required you to go to:
             An emergency room              _____
             See a doctor                   _____
             Stay in a hospital             _____
             Require x-rays                 _____
             Or miss more than 3 days of practice or competition _____?

FX, SPRAINS, DISLOCATIONS, STRAINS, CARTILAGE INJURIES
a. Neck                           f. Fingers                         k. Ankle
b. Shoulder/Clavide               g. Back (Upper/ Lower)             l. Foot
c. Elbow                          h. Hip                             m. Facial Injury
d. Wrist                          i. Knee                            n. Chest/Ribs
e. Hand                           j. Upper/Lower Leg                 o. Pelvic injury

Indicate in the lines below the date (approx) and body part injured, the nature of the injury, whether L/R, rehab
received, surgery (if applicable), ongoing care required.

____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Orthopedic Operations: present or previous (date and nature of operation) _________________________

________________________________________________________________________________________________

Do you need a brace for your injury when you play?                              _______________

Has your injury required that you tape the area to play?                        _______________

Any other significant injury to your body? (please explain)                     _______________


NON CARDIOVASCULAR PROBLEMS:
1. Any history of the following:
    a. Heat Illness _______b. Diabetes ______ c. One of a paired organ ________ d. Inf. Mono _____

2. CHRONIC health condition requiring treatment. __________________

3. Do you wear (glasses /contacts ) to participate in sports?________
   Do you wear dental braces, bridges or plates?________

4. Have you ever taken steroids, other medications for body building or nutritional supplements? ________

5. Do you smoke or chew tobacco? (note cigs or dips/day and years of smoking /chewing) ________

6. Do you drink alcohol/beer? _____________________________
   How much do you consume in one night on average? ________
   HX of substance abuse _________________________________
   Are you presently involved in a recovery program? __________
   Family member who has an alcohol or other substance abuse problem?__________________________

If YES to ANY of the above, please explain below - (note intervention, medication and dosing schedule where appropriate)
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________

7. Other Medical Problems :______________________________________________
8. Surgeries or Hospital Admissions: _______________________________________
9. Last Dental Examination:_______________________________
PHYSICAL EXAMINATION
DATE OF EXAM: ___________________

BP: _________ P: ________ HGT: ________ WT: _______ BMI: ____
Peak flow (if history of asthma)______________

Skin:

Ears/Nose/Throat

Mouth/Teeth :

Neck/Thyroid:

Respiratory:

Cardiac:

                  Squat ______________________                         Valsalva ___________________


Abdomen:             BS _________              Liver __________ Spleen _________ Hernia _____________


ASSESSMENT/PLAN:
         ____        Cleared without restriction;
         ____        Cleared, with recommendations for further evaluation or treatment (eg, "recheck blood pressure in 1
                      month");
         ____        Not cleared—clearance status to be reconsidered after completion of further evaluation, treatment, or
                      rehabilitation; and
         ____        Not cleared for certain types of sports or for all sports.

Pending Information: _______________________________________________

RESTRICTIONS OR FOLLOW -UP: __________________________________________

MEDICATIONS ORDERED: ______________________________________________

REFERRAL: __________________________________________________________

HANDOUTS GIVEN: TSE_____                 SBE________ Gyn Exam ______


PHYSICIAN'S SIGNATURE _______________________________________________


PHYSICIAN'S NAME (PRINT CLEARLY) __________________________

    ADDRESS ________________________________

               _______________________________

    PHONE NUMBER: (________) - ___________________                      FAX: (________) - _______________________
                             (AREA CODE)               NUMBER               (AREA CODE)     NUMBER
    DOC Bb 12/95 , revised 2/98. 01/00, 5/03

				
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