Washington and LeeUniversity
Preparticipation Sports Exam
To be completed by student/athlete. Provide honest and accurate information. This information may be used by the Sports Medicine Staff, Examining Physicians, and StudentHealthCenter. This form must be completed IN FULL and returned to W&L Athletics before the student athlete will be able to participate in sports.
Student-athlete’s full name: ______Class ______
Sport(s): ______
Date of Birth: ______Sex: M FSS#______
Permanent Home Address: ______
Home Phone: ______
Father’s Work #: ______Mother’s Work #: ______
Family Physician: ______Physician #: ______
Medical History
General:
1. Have you been hospitalized/had surgery in the past year?YN
2. Since your last physical exam for sport participation, have you had any
injuries/illnesses that have kept you from participating for more than 1 week?YN
3. Have you ever had a head injury which resulted in an altered level of consciousnessYN
(disorientation, loss of consciousness, etc)?
4. Are you currently ill or under the care of a physician?YN
5. Are you taking any medication on a daily or episodic basis?YN
6. Do you have any allergies (medication, pollen, insect stings, etc.)YN
Please List ______
7. Do you wear glasses or contacts? If so, when was your last exam? ______YN
8 . Do you have a family member (immediate family) who had a premature deathYN
-under the age of 50 years old due to cardiovascular disease?
9 . Do you currently have an incompletely healed injury?YN
10. Do you have a pin, screw, or plate somewhere in your body? YN
If yes, where? ______
11. Have you ever been diagnosed with a spinal injury, or complication?YN
If yes, when ______
Explain any “Y” answers: ______
______
12. Do you have a history of or take medication for: (Check all that apply)
___Anemia/bleeding trait___Hearing impairment
___Arthritis___Heart problems
___Asthma/allergies/bronchitis___Back/joint injury
___Mononucleosis___Chest pain when resting
___Chronic headaches/migraines___Sudden shortness of breath while exercising
___Chronic indigestion/ulcers___Sudden unexplained fatigue with exercise
___Diabetes___Severe anxiety/depression
___Eating disorder___Epilepsy/seizure disorder
___Head injury/concussion ___Hepatitis
___Menstrual problems___Marfan’s Syndrome or other genetic disorders
___Kidney problems___High blood pressure
___Epilepsy___Collapsed lung
13. Date of last menstrual cycle ______
14. Date of last tetanus shot: ______
15. Dates of Hepatitis B vaccination 1st Dose______2nd Dose______3rd Dose______
16. List ALL medications (including asthma, allergy, and birth control) that you are now taking or
take routinely. ______
______
Cardiopulmonary:
17. Do you have asthma or have you ever been treated for an asthma attack?YN
18. Do you carry and/or use an inhaler when participating in athletics?YN
If yes, give name of inhaler ______
19. Have you ever been diagnosed with a heart murmur or high blood pressure?YN
20. Have you ever been held out of competition for a heart murmur or complication?YN
21. Have you ever experienced an “irregular” heartbeat or dizziness with exercise?YN
22. Have you ever fainted or had the sensation of passing out while exercising? YN
Date(s) ______
23. Have you ever experienced chest pain during or after exercise?YN
Date(s) ______
Musculoskeletal:
24. Have you ever had a facial injury ( i.e. nose fracture)?YN
Explain ______
25. Have you ever had a shoulder injury (i.e. dislocation, stinger)?YN
Explain ______
26. Have you ever had an elbow/arm/wrist/hand injury? (i.e. dislocation, numbness)YN
Explain ______
27. Have you ever had a back injury (i.e. fractured disc, bulging disc)?YN
Explain ______
28. Have you ever had abdominal injuries (i.e. hernia, ruptured spleen)?YN
Explain ______
29. Have you ever had hip/thigh/groin injuries?YN
Explain ______
30. Have you ever had a knee injury (ACL, meniscus, chronic pain)? YN
Explain ______
31. Have you ever had a lower leg/ankle/foot injury (i.e. compartment syndrome)?YN
Explain ______
32. List any surgical procedures that have resulted from a musculoskeletal injury.
______
______
The undersigned, herewith
A. Certifies that the answers to the above questions are complete, correct, and truthful to the best of his/her
knowledge.
B. Fully realizes the Washington and LeeUniversity cannot be held responsible for any previous medical
condition(s) that s/he might have.
C. Fully realizes that misrepresentation of information cold have serious medical implications leading to
injury, and, in extreme circumstances death. Misrepresenting one’s health or medical history may be
cause for disqualification from athletics at Washington and Lee.
SIGNATURE ______DATE ______
(Student-Athlete)
SIGNATURE ______DATE ______
(Parent/Guardian)
Medical Authorization
I hereby authorize the Washington and Lee University Sports Medicine Staff and Emergency Medical Personnel to render medical or surgical care that they deem necessary to my health and well being. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made to notify my parents or the designated emergency contact in the most expeditious manner possible. If the physician is unable to communicate with me, the treatment deemed necessary for my best interest may be given.
I also hereby authorize the Athletic Trainers at Washington and LeeUniversity who are under the direction and guidance of the University team physician, to render any preventative, first-aid, rehabilitative, or emergency treatment that they deem reasonably necessary to my health and well being.
SIGNATURE ______DATE ______
(Student-Athlete)
SIGNATURE ______DATE ______
(Parent/Guardian)
Release of Information
I understand that the Washington and Lee University Sports Medicine Staff and Team Physicians may share amongst themselves for the purpose of treatment, information concerning the illness/injury relative to my past, present, or future participation in athletics at Washington & Lee. Also the above may provide medical information to insurance companies pertaining to the student-athlete as needed.
SIGNATURE ______DATE ______
(Student-Athlete)
SIGNATURE ______DATE ______
(Parent/Guardian)
Shared Responsibility for Sport Safety
Participation in sports requires an acceptance of risk for injury. Your decision to participate in athletics indicates your acceptance of this risk. In order to minimize this risk as a participant, you must be aware of and abide by certain procedures, safety rules, and guidelines. Any improper use or abuse of your equipment could result in injury to you, a teammate, or an opponent. Improper or illegal use of your equipment or technique may result in serious head and neck injuries, paralysis, internal injury, and death. Other injuries in athletics include, but not limited to strains, sprains, fractures, and contusions. Athletes rightfully assume that those responsibilities for the conduct of sports will not intentionally inflict injury upon them, but acknowledge that unintentional injuries, including serious head and neck injuries, paralysis, internal injury, death, sprains, strains, fractures, and contusions, can happen while participating in or training for athletic events. Periodic analyses of injury patterns lead to refinement in the rules and safety decisions, but safety cannot be legislated solely through rules and equipment standards. The responsibility for sport safety must be shared by all involved, and compliance with rules means respect on everyone’s part for the intent, spirit, and purpose of the rules or guidelines.
The undersigned has read and understands the statements above.
SIGNATURE ______DATE ______
(Student-Athlete)
SIGNATURE ______DATE ______
(Parent/Guardian)
To Be Completed by Your Physician:
Pulse/BP/Ht/Wt
Pulse ______Blood Pressure______
Height ______Weight ______
Orthopedic Examination
Joint / Strength / Laxity / CommentsNeck
Shoulders
Elbows
Wrists/Hands
Hips
Knees
Ankles
Physical Examination
Physical ExaminationENT
Cardiovascular
Respiratory
Genitourinary
Gastrointestinal
Musculoskeletal
Neurological/Head
Skin
Renal
____ Released to participate in athletics
____ Referral
Comments: ______
______
Name of Physician ______
Physician’s Signature ______Date ______
Phone ______Fax ______