University of South Alabama Sports Medicine Tryout Requirements

University of South Alabama Sports Medicine Tryout Requirements

Complete the attached paperwork containing the following documents:

• Intercollegiate Athletic Tryout Waiver Form
• Medical History Questionnaire
• AHA Questionnaire
• Sickle Cell Trait Information Sheet / Waiver
• Medical Insurance Information Sheet

Make an Appointment with Student Health Center at (251) 460-7151 for a Pre-Participation Physical Exam (PPE) and Sickle Cell Solubility Test (if needed).

• Complete the following paperwork Prior to your PPE appointment
• AHA sheet questions 1-8 Only
• General Medical History
• Bring completed paperwork along with Pre-Participation Physical Exam Form to your appointment.
• Cost for PPE - approximately$20
• Cost for Sickle Cell Solubility Test –approximately $48

Map to Student Health Services.

• Return Completed Paperwork back to Athletic Training Room after PPE and Sickle Cell Testing (if needed) has been completed along with a copy of your Insurance Card (Front and Back)

South Alabama Athletics

Proof of valid health insurance that covers athletic injuries

• All Primary Insurance policies are subject to approval by the athletic department and must be considered a major medical health care policy
• Supplemental short term policies are NOT accepted
• Policies cannot exclude athletic injuries
• All policies must have out of network benefits
• Allows treatment by Mobile physicians
• Out of network policies must have “guesting privileges”

*A copy of the front and back of the insurance card must be presented at the time of tryout. If a prospective walk-on athlete does not have valid health insurance that covers athletic injuries, he or she will not be able to participate until they have done so.

Examples of insurance NOT accepted:

• Military based insurance
• Ex: Tricare
• Government based insurance
• Ex: Medicaid
• Supplemental insurance policies
• Ex: Aflac
• Kaiser Permanente is Not accepted

UNIVERSITY OF SOUTH ALABAMA

INTERCOLLEGIATE ATHLETIC TRYOUT RELEASE FORM

Student Athlete: ______Date: ______

Sport: ______Jaguar ID: ______

I, ______, wish to try out for a position with a University of South Alabama Intercollegiate Athletic Team. I understand and assume the accompanying risk of physical injury or death from such athletic activity. I or my heirs, executors, administrators or assigns release the University of South Alabama, it’s employees and representatives, from all claims and/or liability whatsoever for any injuries, illnesses or death resulting from such athletic tryouts.

I have no knowledge of any physical impairment or disability that would affectmy participation in the above tryout.

I acknowledge that I MUST show proof of and provide the following information:

• A copy of a current, valid and approved by athletics medical health insurance card (see guidelines)
• A pre-participation physical exam by USA physicians at student health services or licensed physician on proper South Alabama Medical Form.
• Complete a Sickle Cell Trait test. The NCAA requires all tryout participants to complete a Sickle Cell Solubility test or show results of a prior test.

ALL INFORMATION MUST BE RETURNED TO THE DESIGNATED INTERCOLLEGIATE SPORT-ATHLETIC TRAINER PRIOR TO ANY PHYSICAL ACTIVITY.

______

Athlete’s Signature Date

______

Parent/Guardian’s Signature (If under 19 years old) Date

UNIVERSITY OF SOUTH ALABAMA DEPARTMENT OF ATHLETICS

MEDICAL HISTORY QUESTIONNAIRE

Please answer all of the following questions in detail. Incomplete forms may be returned to you resulting in a delay in your physical process. This process must be complete before you will be allowed to participate.

NAME:______Sex:____ DATE OF BIRTH: _____/______/______First Middle Last mm dd yyyy

SSN: ______-______-______JAGUAR ID#:______

SPORT(S):______

(At USA) Primary Secondary Tertiary

LOCAL ADDRESS: ______(AT USA)

______

CityStateZip

LOCAL PHONE: ( )______CELL PHONE: ( )______

EMAIL ADDRESS:______

PARENTS’ NAMES:______ Mother Father

PARENTS’ HOME PHONE: ( ) ( )______

PARENTS’ CELL PHONE: ( ) ( )______

PARENTS’ WORK PHONE: ( ) ( )_______

EMAIL ADDRESS:______

HOME ADDRESS:_________ (Permanent)

______

CityStateZip

IN CASE OF EMERGENCY, PLEASE CONTACT: (other than parent/guardian)

NAME: ______RELATIONSHIP: ______

HOME PHONE:( )______WORK PHONE: ( )______

CELL PHONE:( )______EMAIL: ______

UNIVERSITY OF SOUTH ALABAMA PRE-PARTICIPATION PHYSICAL EXAM FORM

ATHLETE’S NAME: ______JAGUAR ID: ______

SPORT: ______DATE OF BIRTH: ______

Year 1 / Year 2 / Year 3 / Year 4 / Year 5
TYPE OF EXAM / FULL EXAM / VITAL SIGNS / FULL EXAM / VITAL SIGNS / VITAL SIGNS
ACDM. YEAR
EXAM DATE
HEIGHT / In. / In. / In. / In. / In.
WEIGHT / Lbs. / Lbs. / Lbs. / Lbs. / Lbs.
VISION
TEMPERATURE
BP / / / / / / / / / /
PULSE / /min. / /min. / /min. / /min. / /min.

GENERAL MEDICINE PHYSICAL: YEAR 1

Normal / Abnormal Findings/Comments / M.D. Initials
EENT
HEAD
HEART
LUNGS
ABDOMEN
SKIN

Cleared for full participation with no restrictions

Cleared with limitations/restrictions: ______

Not cleared due to: ______

Physician’s Signature: ______Physician: ______Date: ______

ORTHOPEDIC PHYSICAL

Normal / Abnormal Findings/Comments / M.D. Initials
HEAD & NECK
SPINE
SHOULDERS
ELBOWS
ARMS
WRIST/HAND
PELVIS
QUAD/HAM
KNEE
ANKLE/FOOT

Cleared for full participation with no restrictions

Cleared with limitations/restrictions: ______

Not cleared due to: ______

Physician’s Signature: ______Physician: ______Date: ______

GENERAL MEDICINE PHYSICAL: YEAR 3 ONLY

Normal / Abnormal Findings/Comments / M.D. Initials
EENT
HEAD
HEART
LUNGS
ABDOMEN
SKIN

Cleared for full participation with no restrictions

Cleared with limitations/restrictions: ______

Not cleared due to: ______

Physician’s Signature: ______Physician: ______Date: ______

Name ______Jaguar ID ______D.O.B ______

The 12 Element AHA Recommendations for Pre-participation Cardiovascular Screening of Competitive Athletes

Student- Athlete please answer Yes or No to the following 8 questions:
Medical historyabout YOURSELF and Family History:
Personal history – Have you ever experienced:
Yes - No1. Exertional chest pain/discomfort
Yes - No2. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
Yes - No 3. Unexplained syncope/near-syncope
Yes - No4. Elevated systemic blood pressure
Yes - No 5a. Prior recognition of a heart murmur
Yes - No 5b.Heart surgery or diagnosed conditions of the heart
Family history – Do any family member have or have experienced
Yes - No6. Premature death (sudden, unexpected, or otherwise) before age 50 years due to HEART DISEASE, in
1 relative
Yes - No7. Disability from HEART DISEASE in a close relative <50 years of age
Yes - No8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated
cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically
important arrhythmias
Physical examination FOR DOCTORS ONLY!
Yes - No9. Heart murmur
Yes - No10. Abnormal femoral pulses to exclude aortic coarctation
Yes - No11. Physical stigmata of Marfan syndrome
Yes - No12. Abnormal brachial artery blood pressure (sitting position) BP/Left Arm ______BP/ Right Arm ______
*Parental verification is recommended for high school and middle school athletes.
Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
Preferably taken in both arms.37

Physician recommendation for cardiac follow up YES or NO Evaluation Notes:______

Evaluated By:

Physician Name Physician signature Date of Evaluation

GENERAL MEDICAL

Please circle any of the following that you currently have; have had, and/or are currently being treated for:

AnemiaHeat Illness (Cramps, Exhaustion, Etc.)Migraines

AppendicitisHemophiliaMononucleosis

Bladder Illness/InjuryHepatitisMumps

Bleeding TendenciesHerniaPalpitations

Chicken PoxHiatal HerniaPleurisy

DiabetesHigh/Low Blood PressurePneumonia

Drug/Alcohol DependencyHIV/AIDSPolio

Emotional Disturbance (Depression)Kidney Disease/InjurySpleen Injury

EpilepsyLeukemiaStomach Trouble

Freq. or Severe HeadachesLiver Disease/InjurySickle Cell Trait

FibromyalgiaLupusTuberculosis

Hearing DefectMeaslesThyroid Disorder

Heart Disease/Heart SurgeryMenstrual DisorderUlcers

Please explain ANY of the circled responses: ______

GENERAL MEDICAL – PLEASE COMPLETE THE FOLLOWING QUESTIONS:

YES NOHave you ever lost a paired organ (i.e.: kidney, eye, testicle, etc...?

YES NOHave you ever been told that you should wear a brace, be taped, etc.?

YES NOHave you ever been told to have a test or surgery that you did not elect to do?

YES NOHave you ever been in a car accident that you were injured?

YES NOHave you ever been denied participation in a sport?

YES NODo you have any other medical problems not mentioned above?

YES NOHave you ever passed out while exercising?

YES NOHave you ever passed out for any reason?

YES NODo you frequently cough after exercising?

YES NOHave you ever had chest pain while exercising?

YES NO Have you ever been diagnosed with a heart condition, rhythm defect, or suffered a heart attack?

YES NOHave you ever seen a cardiologist, pulmonologist, or neurologist?

YES NOHas anyone in your family died before the age of 50?

YES NOAre there any diseases that run in your family (diabetes, heart disease, etc...)?

YES NOHave you ever been told or you have suspected you have an eating disorder?

YES NODo you have any screws, pins, pacemaker, or other implants?

YES NOAre you currently taking any medications regularly?

YES NOHave you been told to take a medication that you no longer take?

YES NOAre you now or have you ever used an anabolic steroid or growth hormone?

YES NO Have you ever suffered an injury to your genital/groin area?

Please explain any YES answers: ______

VISION AND DENTAL

YES NODo you wear dentures, partials, retainers, etc.?

YES NODo you have full use of both eyes?

YES NODo you wear contacts or glasses?

ALLERGIES

YES NOAre you allergic to any medications that you are aware of? Please circle all that apply: Aspirin, Codeine, Cortisone, Sulfa, Anti-Inflammatory Medications, or Penicillin.

Other Medication Not Listed: ______

YES NOHay Fever?

YES NOInsect Bites or Stings? If yes, what kind of insect(s)? ______

YES NOAny particular food? Explain: ______

YES NOOther Allergies? Explain: ______

HEAD

YES NOHave you ever been knocked unconscious?

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWere you admitted to a hospital or infirmary?

YES NODid you miss any practice or game time due to a head injury or pain?

YES NOHave you ever had a concussion without losing consciousness?

YES NOHave you ever had a seizure (either convulsive or non-convulsive)?

Please explain any YES answers: ______

NECK

YES NOHave you ever had a neck injury or neck pain?

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWas surgery performed?

YES NOWere you admitted to a hospital or infirmary?

YES NODid you miss any practice or game time due to a neck injury or pain?

Please explain any YES answers: ______

BACK

YES NOHave you ever injured your back or suffered from back pain?

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to a back injury or pain?

Please explain any YES answers: ______

SHOULDER

YES NOHave you ever had a shoulder injury?R___ L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to shoulder injury or pain?

Please explain any YES answers: ______

ARM/ELBOW

YES NOHave you ever injured either one of your elbows?R___L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWere you put into a cast or immobilized?

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to arm/elbow injury or pain?

Please explain any YES answers: ______

WRIST/HAND/FINGERS

YES NOHave you ever injured either one of your wrists/hands/fingers?R___L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWere you put into a cast or immobilized?

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to shoulder injury or pain?

Please explain any YES answers: ______

HIP/THIGH

YES NOHave you ever injured either of your hips?R___ L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWere you put into a cast or immobilized?

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to hip injury or pain?

Please explain any YES answers: ______

KNEE

YES NOHave you ever injured either of your knees?R___ L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWere you put into a cast or immobilized?

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to knee injury or pain?

Please explain any YES answers: ______

LOWER LEG/ANKLE

YES NOHave you ever injured your ankle(s)?R___ L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWere you put into a cast or immobilized?

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to lower leg/ankle injury or pain?

Please explain any of the YES answers: ______

FEET

YES NOHave you ever injured either foot?R___ L___

YES NODid you see a physician?

YES NOWere X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NOWas surgery performed?

YES NODid you miss any practice or game time due to foot injury or pain?

YES NOHave you ever been told that you have flat feet or high arches?

YES NOHave you ever used, or been advised to use orthotics?

Please explain any of the YES answers: ______

List and describe ANYOTHER injuries you have sustained, giving dates for all and explaining their occurrence and any current medical problems that you would like to speak with the physicians about: ______

WOMEN ONLY – Female Student-Athletes complete the following:

YES NODo you suffer from irregular menstrual periods?

YES NODo you suffer from severe menstrual cramps?

YES NOAre you currently taking any medications for birth control and/or severe cramps?

If yes, what, how much and how often? ______

YES NODo you have frequent urinary tract infections?

YES NOHave you had any past pregnancies or births?

YES NOHave you ever been treated for anemia (low iron)?

YES NOHave you ever been treated for an eating disorder?

IT IS THE POLICY OF THE UNIVERSITY OF SOUTH ALABAMA DEPARTMENT OF ATHLETICS THAT STUDENT ATHLETES WHO HAVE A MEDICALLY DIAGNOSED PREGNANCY NOT PARTICIPATE IN ANY UNIVERSITY ATHLETIC DEPARTMENT SPONSORED COMPETITION, PRACTICE, OR CONDITIONING ACTIVITY IF PARTICIPATION WOULD PRESENT AN UNREASONABLE DANGER TO EITHER THE FETUS OR THE MOTHER. IN THE EVENT OF A PREGNANCY; THE UNIVERSITY, ITS TEAM PHYSICIANS OR DESIGNATED PHYSICIANS MAY RESERVE THE RIGHT TO HOLD A STUDENT ATHLETE OUT OF PARTICIPATION FOR SUCH REASONS.

STUDENT ATHLETE, ______, AND PARENT OR GUARDIAN HAVE READ, UNDERSTAND AND AGREE TO THE AFOREMENTIONED POLICY ON THE PARTICIPATION OF THE STUDENT ATHLETE. STUDENT ATHLETE AND PARENT OR GUARDIAN AGREE THAT IT IS THE STUDENT ATHLETE’S RESPONSIBILITY TO NOTIFY THE UNIVERSITY’S MEDICAL PERSONNEL OF ANY CHANGE IN MENSTRUAL PERIODS AND/OR REPRODUCTION STATUS. STUDENT ATHLETE AND PARENT OR GUARDIAN UNDERSTAND THAT THE UNIVERSITY DEPARTMENT OF ATHLETICS MAY NOT BE HELD FINANCIALLY RESPONSIBLE FOR ANY PREGNANCY TESTS OR OTHER MEDICAL PROCEDURE THE STUDENT ATHLETE MAY UNDERGO DUE TO CHANGES IN THE STUDENT ATHLETE’S REPRODUCTIVE SYSTEM.

DATE: ______SIGNATURE: ______

PARENT OR GUARDIAN’S SSN: ______

SIGNATURE REQUIRED IF PARENT/GUARDIAN: ______

UNDER 19 YEARS OF AGE

University of South Alabama Sports Medicine

Sickle Cell Trait Information Sheet/Waiver

Revised August 2015

Sickle Cell Trait Testing:

• The NCAA requires that all Division I student-athletes who are beginning their initial year of eligibility and student athletes trying out for an intercollegiate team, including transfer student-athletes to complete a sickle cell solubility test, show results of a prior test, or sign a waiver releasing the school from liability if they decline to be tested. Sickle cell solubility test results or waiver must be completed before participating in athletic-related activities, including intercollegiate athletics events, strength and conditioning sessions, tryouts, practices, or competitions. Division I Bylaw 17.1.5.1

Please insert your name, date of birth, and sport below then select one of the options below and return this form and the supporting documentation.

Name ______

LastFirstMiddle

Sport(s): ______J#______Date of Birth ______/______/______

Please choose ONE of the following:

A._____ I will be tested by a proper sickle cell provider prior tryout physical examination.Results must be presented with tryout physical package.

B._____ A copy of my newborn screening records pertaining to sickle cell trait are attached .

C._____A copy of my sickle cell trait test from a physician or other authorized medical care provider is attached.

D._____TheUniversity of South Alabama Sports Medicine staff has a copy of my sickle cell trait test.

I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full knowledge of its significance. If I am under 19 years of age, my parent and/or guardian has also signed below.

Student Signature: ______DATE ____/____/____

Parent or Guardian Signature ______DATE ____/____/____

(Required if student athlete is under 19 years of age)

INSURANCE AND FINANCIAL RESPONSIBILITY

ALL UNIVERSITY OF SOUTH ALABAMA INTERCOLLEGIATE STUDENT-ATHLETE PARTICIPANTS MUST BE COVERED BY A MAJOR MEDICAL HEALTH INSURANCE THAT HAS BEEN APPROVED BY JAGUAR ATHLETICS BEFORE PARTICIPATING IN ANY PRACTICE, GAME, AND/OR COMPETITION. The student-athlete’s health insurance policy must cover PARTICIPATION in intercollegiate athletics and have an inclusion for intercollegiate athletic related injuries and/or illnesses, and shall be considered the PRIMARY insurance coverage for all athletic related injuries. Some insurance companies may be impermissible due to the compatibility with the athletic institutional excess athletic coverage, (i.e. TRICARE, KEISER, MEDICAID). Please discuss with the sports medicine staff if you have any questions. The student-athlete must complete a Health Insurance Information / Authorization Form and supply a photocopy (front & back) of the health insurance card on a yearly basis.