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					Montclair State University First Year MSU Athlete Medical History Form
Sport:
Name: Std. ID# Height: Age: Weight: Male

Date:
Freshman Transfer Former School

Female

DOB:

E-mail Address:

Dorm or Off Campus Address: Dorm/ Off Campus Phone: Home Address: Home Phone: Parent/Guardian Name(s): Address (If different than above): Phone: Cell Phone:

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In case of an emergency and a Parent or Guardian can not be reached, please contact: Name: Address: Relationship: Phone:

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ImmunizationsState law requires all students show proof of immunizations. These must be on file in the Health and Wellness Center. Call 973-655-4361 for more information. STOP ! I attest that the information contained in this form is truthful, correct, and complete to the best of my knowledge. I understand that any medical information withheld, incomplete, or incorrect may result in incomplete or incorrect medical treatment and may disqualify me from participation. I also understand that voluntary withholding of medical information could void payments by Montclair State University’s insurance carrier. I did not withhold any information about any physical problems in order to participate. Athletes Signature_____________________________________________ Date______________ Parents Signature______________________________________________ Date______________ 1

Medical History: Do you have or have you had any of the following health problems? Please check “yes” or “no”. If yes, please explain in the space provided at the bottom of the page. Give date(s) if possible.

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YES YES YES YES YES NO NO NO NO NO Are you allergic to any medication? Are you allergic to any food or insects? Do you have seasonal allergies or hay fever? Do you carry an anaphylactic kit or epipen? Do you take any prescription or nonprescription medication regularly? Do you have Diabetes? Are you Insulin dependent Do you use a pump or injection? Do you have Epilepsy? Convulsions? Have you or a relative suffered from Cancer? Have you or a relative suffered from a Stroke? Do you or a family member suffer from Sickle Cell Anemia? Do you or a relative suffer from Marfan’s Syndrome? Have you ever had Mononucleosis, Hepatitis, Tuberculosis, or any other Infectious disease? Do you have Anemia or other blood Immune system disease? Do you have any other inherited Disease or infectious diseases (ie. Lyme, Meningitis, HIV or T.B.) Have you had Kidney Disease or a Urinary Infection? Have you had any organs removed? (Eye, Kidney, Testicle, Ovary) Have you had a Hernia/Appendix Surgery? Have you had a Tonsillectomy? Have you been hospitalized overnight or longer? Have you had surgery that was non-orthopedic? YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Do you have Asthma? Do you carry an inhaler? What is the Medication: Any other Lung disease? Have you or a relative suffered from Blood disease? Have you had a cough lasting longer than 3 weeks? Is there a history of Heart disease in your family? Have you or a relative suffered from heart trouble or Heart attack? Do you or your parents have High Blood Pressure? Low BP? Do you have a Heart Murmur? Do you get Heart palpations: a racing Heart, or irregular heart beats? Do you have chest pain with exercise Do you get shortness of breath with exercise? Do you get dizzy or have you fainted during exercise? Have you seen a Cardiologist/heart Specialist? When? Have you ever had a EKG or Echocardiogram? Has any relative suddenly died at 40 years or less of causes other than accident? Age? Have you had any skin infections or rashes? Do you bruise or bleed easily? Have you had a cyst removed? Do you suffer from chronic stomach, Gastrointestinal, or bowel issues? Do you have any physical aliments? Do you have any mental illnesses? Have you ever been diagnosed ADD or ADHD? Have you had a Tetanus Shot within the last few years? Date: Does exercising in heat cause you problems? Have you ever been diagnosed with Anxiety, depression, or other Psychological disorders? If yes what medication are you own. Has a doctor every denied you or Recommended against your Participation in a sport or physical Activity?

YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO

YES YES

NO NO

YES YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO NO

YES YES YES YES YES YES

NO NO NO NO NO NO

Please explain any “yes”

YES

NO

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Nutritional Profile/Habits: Do you use or have you used any of the following. Please check “yes” or “no”. If
yes, please explain at the space provided below. Give date(s) if possible. YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO Smoking/Smokeless tobacco? Creatine? MET-RX? Ergogenic Aids? Herbal Supplements? Androstenedione? Heavy Caffeine intake? (i.e. Soda, Coffee, ENERGY DRINKS) Have you ever been diagnosed with an Eating disorder such as anorexia or Bulimia? YES YES YES YES YES NO NO NO NO NO Other Dietary Supplements? Do you use Steroids? Recreational Drugs? GNC Products? Ephedra?

Please explain any “yes”

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Female Athletes: YES YES NO NO Do you have regular periods? Length of cycle? Date of Last period? YES YES NO NO Menstrual Disorder? Do you take oral contraceptives?

Please explain any “yes”

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Eyes: YES YES YES Do you wear eyeglasses? Do you wear contact lenses? Does anyone in your family suffer from Glaucoma? Date of last eye exam? Please explain any “yes” NO NO NO YES NO Have you ever had an eye injury? YES NO Do you get blurred vision with exercise? YES NO Do you have any visual impairment? What do you wear during play

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Dental: Any false teeth, bridges or plates? Do you wear a custom made mouthpiece when you play? Please explain any “yes” YES YES NO NO YES NO Do you have braces? YES NO Do you have regular dental exams? When was your last dental exam?

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Ears: YES YES YES YES NO NO NO NO Have you ever had an ear injury? Do you have a hearing loss? Have you had a perforated eardrum? Do you wear hearing aides? YES YES YES NO NO NO Any drainage from your ears? Do you wear hearing aides when playing Have you had cauliflower ear?

Please explain any “yes”

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Nose: YES YES YES YES YES NO NO NO NO Do you have nasal blockage? Do you have frequent nosebleeds? Have you ever broken your nose? Have you ever had nasal surgery? NO Do you have sinus problems?

Please explain any “yes”

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Skeletal Structure: Have you had any of the problems with any of the following body parts? Please check “yes” or “no”. If yes, please explain at the space provided below along with number of question. Give date(s) if possible. 1. YES 2. YES 3. YES 4. YES 5. YES 6. YES 7. YES 8. YES 9. YES 10. YES 11. YES 12. YES 13. YES 14. YES 15. YES 16. YES 17. YES 18. YES 19. YES 20. YES 21. YES 22. YES 23. YES 24. YES 25. YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Any shoulder injuries? Sprain/dislocation/rotator cuff, unknown? Did your shoulder ever “pop out”? Any clicking, impingement or tendonitis? Any shoulder surgeries? Rehab? Any shoulder surgeries recommended but not completed? Do you wear a shoulder brace? Any elbow injury/surgery/rehab? Wrist, hand, Finger injury/surgery/rehab? Any knee injury? Sprain/Dislocation/unknown? Did your knee ever “pop out” Any tendonitis, ligament, or cartlidge damage? Any clicking, locking, or give way sensations in knee? Osgood-Schlatters Disease (knee)? Any knee surgeries? Doctor? Any knee surgeries recommended, but not completed? Do you wear a knee brace? Bad thigh bruise? Bad hip pointer, hip bruise or other hip injury? Groin, quad or hamstring pull? Have you had shin splints or lower leg stress fractures? Any ankle injuries? Sprains/Fractures/Torn Ligaments/unknown? Ankle surgery? Treatment? Rehab? Achilles tendon injury? Foot injury/surgery/rehab? Do you have a bunion? Surgery for a bunion?

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Skeletal Structure Cont. 26. YES 27. YES 28. YES 29. YES 30. YES NO NO NO NO NO Ever had “Turf toe”? Any foot stress fracture? Where? Do you have flat feet? Do you use orthotics? Have you ever been treated by a podiatrist? (foot doctor) Do you visit any other specialist(s)?

Head and Neck: 31. YES NO 32. YES 33. YES 34. YES 35. YES 36. YES 37. YES 38. YES 39. YES 40. YES 41. YES Back: 42. YES 43. YES 44. YES 45. YES 46. YES 47. YES 48. YES 49. YES Other: 50. YES 51. YES 52. YES 53. YES NO NO NO NO NO NO NO NO NO NO

Have you had a concussion and/or a period of unconsciousness? How many? Did you miss playing time? Did you see a doctor or have a MRI/CAT scan for a head or neck injury? Have you been hospitalized for a head or neck injury? Do you suffer from frequent headaches migraines while exercising? Have you had a pinched nerve? Burner? Stinger? Whiplash? Have you had physical therapy for this problem? Do you visit a chiropractor regularly for this or any other problem? Have you suffered seizures due to head injury? Is there a family history of Seizures? Have you ever been baseline or impacted tested? Have you ever been tested after a concussion?

NO NO NO NO NO NO NO NO

Any back injuries? Surgery? Do you have a postural abnormality or scoliosis? Do you have frequent back pain? Do you have pain radiating to your legs? Do you have a difference in leg lengths? Have you every been treated by a chiropractor? Do you visit a chiropractor regularly? Have you every been treated by a physical therapist for your back pain?

NO NO NO NO

Do you have any other medical abnormality we have not asked you about? Explain below. Have you had any other injuries and/or surgeries that we have not asked you about. Explain. Are you currently being treated for any other injury or condition not listed above? Have you ever received a cortisone injection or herbal injection? Where? Why?

Please explain any “yes”

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For Staff use only:

Physical Examination
(To be completed by the physician or medical staff) Pulse Rate:

Blood Pressure: Cardiac/Heart: Lung Sounds: Abdomen: Genitalia: Skin:

Orthopedic Exam/Assessment:
Foot/Ankle: Knee: Hip/Thigh: Back: Head/Neck: Shoulder: Elbow/Hand/Wrist: Comments:

Conducted by

I certify that I have reviewed the history and examined the above student and I recommend: Student is approved for full participation with no limitations. Student is approved pending additional information/tests. Once completed the student is approved for full participation. Student is approved for participation with limitations. Please explain. Student is referred to other health care professional prior to clearance Student is not approved for participation.

Physician/Nurse Practitioner/Physician Assistant’s Signature Print Physician name & address or stamp -

Date

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