Supplemental Sports Pre-participation History Form
Name: Sport: Today’s Date:
Email Address: Cell Phone#: Male Female
Date of Birth: Age: Class: Years of Participation 1 2 3 4 5
Medication: Please list ALL of the prescription and over-the-counter medicines and supplements (herbal, nutritional, performance enhancement, etc) that you are currently taking.
Allergies and/or drug reaction: please list identify specific allergy bellow: medicine Pollens Food Stinging insects
Yes / No1. Have you been diagnosed with any NEW medical conditions within a year?
(Allergies, cardiac conditions, psychological conditions, etc)
2. Do you have chronic illness or see a physician regularly for any particular problem?
3. Do you take any nutritional supplements, performance enhancement substances, or energy drinks? If so please list ALL.
4. Have you ever had any surgery, broken a bone (fracture), had to wear a brace or cast?
5. Has anyone in your family died before age 50? If yes, explain below.
6. Do you have asthma? Do you wheeze or cough after exercise?
7. Have you ever passed out during or after exercise or stopped exercising because of dizziness/fainting?
8. Have you had chest pain and/or difficulty breathing during or after exercise?
9. Have you ever suffered a heat and/cold related illness?
10. Have you sustained any injury or illness this past year? (sprain/strain, Mono, MRSA, etc)
11. Do you currently have an unhealed injury?
12. Have you ever had a concussion or whiplash? If yes, Total # in past? When? Have you lost conscious?
13. Have you diagnosed as ADD/ADHD? When? Medication?
14. Do you have any unpaired organ? (eyes, ears, kidneys, lungs, etc)
15. Have you tested for sickle cell traits? If yes, S-C trait: positive negative
16. Have you had any illness, disease, or disorder that has not been mentioned?
(eating disorder, seizure, depression, anxiety, infection, skin, etc)
17. Are you aware of ANY medical reason you should NOT participate in intercollegiate athletics?
18. Do you have anything you wish to discuss with the physician?
19. (Female Only) Do you have any concerns about your menstrual cycle?
Please explain All YES responses below:
The above information is both complete and accurate.
Student-Athlete’s Printed Name: Signature:
Date: Reviewed by Health Care provider:
Physical Examination
Name: Sport: Date of Exam:
Cell Phone#: Male Female Date of Birth: Age:
To be completed and signed by a licensed health care practitioner (MD, DO, PA or NP) after reviewing the health history.
BP Pulse WT HT BMI
Vision: (R) (L) Date of last Tetanus shots:
Blood Testing (optional): hemoglobin grms/%, S-C trait: positive, negative, Decline (fill out waiver)
Urinalysis:
1. Musculoskeletal Exam:
Normal Abnormal Description of abnormal findings
Feet/Ankle
Knee
Hip/Lower back
Shoulder
Arm/Wrist/Hand
Other joints
Alignment problems
(ie. Leg length, Scoliosis)
Spine/Posture
Head/Face/Neck
Estimate of strength
Estimate of flexibility
2. Cardiovascular and Pulmonary Exam:
3. Other Exam (if indicated by history):
4. Assessment: No problems found
Other:
5. Recommendations for Participation: Unlimited
Limited to:
Deferred until:
6. Reexamine: Yearly and after any injury/illness that limited participation for longer than 2 weeks
Other:
Memo:
Physician’s Printed Name: Date:
Physician’s Signature: Phone#:
Address:
WAIVER OF LIABILITY FOR DECLINE OF SICKLE CELL SOLUBILITY TEST
1. In consideration for receiving permission to participate as a Hood College student athlete, I have decided to decline to undergo a sickle cell solubility test. As a result, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE, Hood College, their officers, agents, servants, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted.
2. I am fully aware of the unusual risks involved and hazards connected with participating without undergoing the sick cell solubility test. I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, which may be sustained by me, or any loss or damage of property, owned by me, as a result of being engaged in such activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES OR OTHERWISE.
3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.
4. I understand that Hood College does not maintain any insurance policy covering any circumstance arising from my participation in this event without undergoing a sickle cell solubility test, or any activity associated with or facilitating that participation. As such, I am aware that I should review my personal insurance & medical portfolio.
5. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Maryland.
6. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.
PARTICIPATING STUDENT ATHLETE
Student Athlete Printed Name Student Athlete Signature Date
PARENT/GUARDIAN
If Participant is under the age of 18, Parent/Guardian consents to the minor’s participation in the event, consents for Hood College to seek reasonable and necessary medical treatment for Participants during such event or associated activities, and agrees to be responsible for any cost of such treatment.
Parent/Guardian Printed Name Parent/Guardian Signature Date