Health_History-Insurance_Form_Packet

							                                   Medical Eligibility Forms
                                               &
                  Pre-Participation Health History and Insurance Information
______________________________________________________________________________

TO:           Prospective VWC Athletes

FROM:         Virginia Wesleyan College Athletic Training Department

SUBJECT:      Medical Eligibility Forms & Pre-Participation Health History and Insurance Information

The following pages include forms and information necessary to be medically eligible to participate in
intercollegiate athletics at VWC. We request that you complete this process at least two weeks prior
to participating in any pre-season or non-traditional practice periods. Medical eligibility must be
renewed each academic year. All medical eligibility ends following the completion of the spring post-
season competition period. Health History Updates will be done at the beginning of each subsequent
athletic season. Please read the steps listed below and respond to ALL data requested.

STEP 1:       Complete the Health History and Insurance Information Form

STEP 2:       Read Virginia Wesleyan College: Insurance and Athletics found online at:
              http://vwcathletics.com/informaton/athletic_training

STEP 3:       Read NCAA’s ADHD Documentation Checklist (if applicable) found online at:
              http://vwcathletics.com/informaton/athletic_training

STEP 4:       Mail completed form to: Virginia Wesleyan College
                                      Athletic Training Department
                                      1584 Wesleyan Drive
                                      Norfolk, VA 23502-5599


If you have any questions please call the Athletic Training Room at (757) 455-3417
                             VIRGINIA WESLEYAN COLLEGE
                        PARENTS’ INFORMATION/ INSURANCE FORM

        Virginia Wesleyan College Athletics’ sports accident policy provides insurance for
student-athletes for injuries occurring while participating in the play or practice of intercollegiate
sports for Virginia Wesleyan. Its benefits are “IN EXCESS” or “SECONDARY” to any other
collectible group insurance benefits. All claims for benefits must first be filed with the group
insurance company providing coverage for the student-athlete, including parents’ insurance.
After the primary insurer has paid all available benefits, our athletic insurance company will pay
any remaining amounts, subject to limitation of our insurance policy.
        We, as the school, DO NOT have the option of waving the requirement of filing with your
group insurance.

    *Please make a copy of your Insurance card (front & back) and attach it to this form.*

Please Print or Type the Following Information
Athlete’s Name: _______________________Sport(s)____________________________
Date of Birth (MM/DD/Year)____________
Athlete’s Home Phone:__________________Athlete’s Campus Phone/Cell___________
              Father/Guardian             OR           Mother/Guardian
Name________________________________ ____________________________
S.S.#________________________________ ____________________________
E-mail Address________________________ ____________________________
Home Address_________________________ ____________________________
              _________________________ ____________________________
              _________________________ ____________________________
Home Phone _________________________ ____________________________
Work Phone _________________________ ____________________________
Other Phone _________________________ ____________________________
Name of Employer______________________ ____________________________
Name of Insurance Company that covers your Child.
_______________________________________________
Name of person on policy (If not in athletes name)_______________________________
Address of Insurance Company______________________________________________
                            _______________________________________________
Phone Number of Insurance Company______________________________________
Group #______________________                   Policy #____________________________
Is the Insurance Offered by a HMO? Yes No Is it a PPO? Yes No_______________
Is there a Physician in your network that may treat your child? Yes No
Please give their Name and Phone Number: ___________________________________

Do we need a referral from a Primary Care Physician to see another Physician?
Yes No If yes who is your Primary Care Physician? Name______________________
Address_____________________________________________ PHONE:____________
Do we need to contact your insurance company before we schedule an appointment with a
Physician, VA? Yes No If yes, what is their phone number for referrals?
_________________________________________________________________________
                                                    Preferred
       Athlete’s Name
                                                    Name
       S.S.#(optional)                              Sport

       Email @vwc.edu                               Phone #



Allergies:

          Agent               Yes     No    Specific Agent and Reaction
          Medications

          Food

          Bee Stings

          Environmental

          Other

Medications:
List all medications (including Over-the-Counter (OTC)) taken in the past 12 months for more than
two weeks in a row (use reverse for additional medications if needed). *If taking medications to
treat ADD/ADHD, please refer to ADHD Document Checklist found online at
http://vwcathletics.com/informaton/athletic_training.*

                                  Current
       Medication                   Use       Duration of Use
                                 Yes   No




Surgical History
Please list all non-Orthopedic surgeries you have had (use if needed):

                  Nature of Surgery                                 Date
Illness History:
Have you ever been told you have any of the following conditions in the past?

      Condition         Yes   No   Condition            Yes   No   Condition         Yes   No
                                   Hypertension                    Recurrent
      Anemia                       (high blood                     Urinary tract
                                   pressure)                       infection
                                   Hypoglycemia                    Stomach
      Arthritis
                                   (low blood sugar)               Problem
                                                                   Substance
      Asthma                       Kidney stone
                                                                   abuse
      Bleeding                     Hepatitis or Liver              Thyroid
      Problem                      disease                         problem
      Cancer                       Lung disease                    Seizures
                                                                   Sexually
      Diabetes                     Migraines                       Transmitted
                                                                   Disease
                                                                   Syncope
      Eye Problems                 Ovarian Cyst
                                                                   (fainting)
      Hearing loss                 Rheumatic fever                 Other
      HIV                          Single kidney
      Hernia                       Single testis

In the space provided answer the following questions. Provide as much detail as possible (dates,
treatment, tests) for all positive responses (use reverse if needed):


        Do you have any known heart
        condition?

        Have you ever been told you
        have a heart murmur?

        Have you ever been told you
        have an eating disorder?

        Where you ever told you have
        infectious mononucleosis (mono)

        Do you wear any type of dental
        appliance?

        Do you wear glasses or contacts?
        Do you wear them to compete?

        Are you under the care of a
        doctor for any chronic conditions?

        Have you gained or lost more
        than 10 pounds in the past year?

        Have you ever been told you
        have Sickle Cell trait?
        Have you ever been involved in a
        motor vehicle accident?


        Female athletes only
        When was your first menstrual
        cycle?
        When was your last menstrual
        cycle?
        Since your cycles began have you
        gone for more than 4 months
        with a cycle?
        What is the typical interval
        between your cycles?
        What is the typical duration of
        your cycles?
        Do you experience significant
        pain or cramping with your
        cycles?
        When was your last PAP smear?

        Do you take oral contraceptives?

Injury History:
Have you had any of the following injuries?

        Condition           Yes   No   Condition         Yes    No   Condition        Yes   No
        Ankle Sprain                   Muscle Strain                 Joint
                                                                     Dislocation
        Back Pain                      Stress Fracture               Rotator Cuff
                                                                     Injury
        Bursitis                       Tendon or                     Shin Splints
                                       Ligament
                                       Injury
        Joint Instability              Tendonitis                    Bone Spur or
                                                                     Chip
        Knee Injury                    Fracture                      Joint
                                                                     Separation




For all questions with a Yes response, please provide details of this injury below:

       Injury                           Date        Treatment
In the space provided answer the following questions. Provide as much detail as possible (dates,
treatment, tests) for all positive responses (use reverse if needed):

       Have you ever had joint
       exploration, reconstruction or
       arthroscopic surgery?
       Have you ever had an injury
       resulting in you missing more
       than 1 week of games, practices.
       Or general participation?
       Have you ever had a joint,
       tendon or bursa injection or
       aspiration?

       Do you presently use a brace or
       splint for practice or competition?


       Have you ever had heat stroke,
       heat exhaustion or heat cramps?


       Have you ever had a concussion
       or head injury?


       Have you ever had a neck injury?


       Has any doctor ever
       recommended you not
       participate in athletics?




Family History:

Have any members of your family (parents, siblings, grandparents, aunts/uncles or cousins) had any
of the following conditions?

           Condition                                                            Yes   No

           Heart attack before the age of 50 (male) or 60 (female)
           Angioplasty or Bypass Surgery before 50 (male) or 60 (female)

           Sudden or Unexplained death?

           Collapse during physical activity

           Hypertension (High blood pressure)

           Heart Murmur or valve replacement

           Marfan’s syndrome

           Seizures or Epilepsy

           Asthma or other lung disease

           Sickle Cell Disease

           Diabetes

           Depression




____________________________                          _______________
      Athlete’s Signature                                   Date


If Athlete is under 18 year of age:




____________________________                          _______________
      Parent’s Signature                                    Date