Fisher College Sports Medicine

Fisher College Sports Medicine

Student-Athlete Pre-Participation Form

Instructions for Completion:

●Student-athletes that fail to complete this form fully and accurately will not be allowed to participate in athletics.

●Be sure to mark every answer. After marking yes to a question, please thoroughly describe the condition in the space provided. Information to include: right or left side, injury, treatment, date of injury, etc.

●If you are 18 years of age, you must have your parents or guardians read and sign where indicated.

●You must have and provide documentation of a physical exam completed by a physician prior to the start of your competitive season every year.

●To ensure proof of insurance, we are requiring student-athletes to send in a photo copy (front and back) of their medical insurance card. Failure to provide accurate documentation of insurance coverage will result in a delay in medical clearance.

●Return Forms to:

Fisher Athletics

Attn: Fisher Sports Medicine

118 Beacon Street

Boston, MA 02116

●All forms should be received by the Sports Medicine Staff no later than Aug 1st

• Forms to be handed in include:
• This packet
• ADD/ADHD medical disclosure (if applicable)
• Annual physical form
• Immunization Record
• Copy of insurance card (front and back)

Please Print Legibly

Personal Information
Student Name: / Sport(s):
Class: / Institution:
Permanent Address:
School Address:
Email: / Cell Phone #:
Gender: / DOB: / Fisher ID #:
Insurance Information
Do you have the Fisher Student Insurance Plan?
Insurance Company Name: / Plan Type:
Policy Holder Name: / Policy Holder DOB:
Policy Number: / Group Number:
Emergency Contact Information
Primary Contact Name: / Relationship:
Home Phone #: / Cell Phone #: / Work Phone #:
Secondary Contact Name: / Relationship:
Home Phone #: / Cell Phone #: / Work Phone #:
Please list any known allergies:
Please list all the medications you are currently taking:

Personal Health History

Yes / No
1. / Have you had an illness requiring medical attention in the past year?
2. / Are you currently under observation or being treated by a physician for any problems?

You MUST explain all “YES” answers below:

3. / Have you ever had any of the following conditions?
NEVER / CURRENTLY / PAST
a. / Anemia/Abnormal Bruising
b. / Arthritis
c. / Bleeding Disorder/Hemophilia
d. / Chicken Pox
e. / Cancer/Tumor/Cyst
f. / Diabetes
g. / Epilepsy/Seizures
h. / Heart Attack/Disease
i. / Hepatitis/Liver Problems
j. / High Blood Pressure
k. / High Cholesterol
l. / Kidney Injury/Disease/Stones
m. / Marfan Syndrome
n. / Meningitis
o. / Mononucleosis (Mono)
p. / Mumps/Measles/Rubella
q. / Rheumatic Fever/Whooping Cough
r. / Sickle Cell Trait/Disease
s. / Spleen Injury
t. / Stroke/Blood Clots
u. / Thyroid Disease/Goiter
v. / Tuberculosis
w. / Other (specify)

You MUST explain all “YES” answers below:

ADD/ADHD

Yes / No
4. / Are you currently being treated for, or have you ever been diagnosed with, ADD/ADHD?
5. / Do you currently take any medication for the treatment of ADD or ADHD?

If yes, you must complete the ADHD documentation requirements mandated by the NAIA Drug Testing Medical Exception Policy for banned

Substances. This applies if you are taking a stimulant medication (Ritalin, Adderall, etc.).

General Medical Conditions

6. / Have you ever had any of the following skin conditions?
NEVER / CURRENTLY / PAST
a. / Urticaria (Hives)
b. / Eczema
c. / Psoriasis
d. / Fungal Infection (Athletes Foot, Finger/Toe nails)
e. / Impetigo
f. / Shingles
g. / Acne (Severe)
h. / MRSA
i. / Other

You MUST explain all “YES” answers below:

7. / Do you currently have, or have you in the past had, any of the following mental health disorders?
Condition / Yes / No
a. / Anxiety
b. / Depression
c. / Bipolar Disorder
d. / Other
e. / Do you currentlyhave, or have you in the past had, an alcohol/drug dependency issue?
f. / Do you feel extremely guilty after over-eating?

You MUST explain all “YES” answers below:

Men Only

Yes / No
11. / Have you ever had any prostate problems?
12. / Have you ever found a lump or mass, or lost a testicle?
13. / Have you ever had an injury to your testicles?
14. / Are you terrified of gaining weight?/ Losing weight?

You MUST explain all “YES” answers below -If yes, please include letter from doctor indicating diagnosis, treatment plan and current medication and dosage per NAIA Banned Substance disclosure ruling

Women Only

Yes / No
15. / Do you have a history of irregular menstrual periods?
16. / Have you ever missed your period for 3 consecutive months or more?
17. / Do you suffer from severe cramps or excessive flow?
18. / Are you terrified of gaining weight? Losing weight?
19. / Have you ever had an abnormal PAP smear or pelvic exam?

You MUST explain all “YES” answers below:

Family History

Please check all that apply to your family history. If you mark “yes” you must explain.

20. / Condition / Yes / No / Relation / Explain
a. / Cancer
b. / Epilepsy/Seizures
c. / Heart Attack/Disease
d. / High Blood Pressure
e. / High Cholesterol
f. / Mental Health Disorder
g. / Marfan Syndrome
h. / Sickle Cell Trait/Disease
i. / Sudden Death
j. / Stroke
k. / Diabetes
l. / Other

Diet/ Nutrition

Yes / No
21. / Have you recently begun a weight loss/diet program?
22. / Has your weight fluctuated more than 15 lb in the last year?
23. / Have you been diagnosed with or treated for an eating disorder?
24. / Have you attempted to follow definite rules regarding your eating (ex: a calorie limit, a set amount of food, or rules about when you should eat?
25. / Have you ever consulted a nutritionist?
26. / Would you like to change your body? If yes, how would you like to reach this goal?
27. / Do you take any performance enhancing supplements?
28. / Have you been consciously trying to restrict the amount of food you eat to influence your shape or weight?

You MUST explain all “YES” answers below:

Allergies/ Medication

Yes / No
29. / Are you allergic to any medications (penicillin, sulfa, aspirin, codeine, etc)?
30. / Do you have any food, insect, or environmental allergies?
31. / Have you ever been told you should carry an Epi-Pen auto-injector for your allergies?
32. / Have you ever had an unexplained allergic reaction?
33. / Are you currently taking any over-the-counter medication on a consistent basis?
34. / Please list all prescription medications you take on a consistent basis?
(e.g. birth control pills, allergy medication, etc.)

You MUST explain all “YES” answers below:

Asthma – please include copy of prescription (copy of box w/prescription label acceptable)

Yes / No
35. / Have you ever had an asthma attack or difficulty breathing?
36. / Have you ever been diagnosed with asthma and/or exercise induced asthma?
a. / If yes, how many acute asthma attacks have you had in the past 12 months?

You MUST explain all “YES” answers below:

Cardiovascular Risk Factors

Yes / No
37. / Have you ever been told that you have a heart murmur?
38. / Have you ever been told that you have an irregular heart beat/arrhythmia?
39. / Has any family member or relative died of heart problems and/or sudden death before age 50?
40. / Do you or any family members have a history of cardiomyopathy?
41. / Have you ever had an EKG or ECHO of your heart?

You MUST explain all “YES” answers below:

42. / During exercise, have you ever experienced any of the following?
NEVER / CURRENTLY / PAST
a. / Chest Pain
b. / Dizziness
c. / Shortness of Breath
d. / Excessive Fatigue
e. / Fainted
f. / Loss of Consciousness
g. / Other

You MUST explain all “YES” answers below:

Other Conditions

43. / Have you ever suffered from a heat related injury?
NEVER / CURRENTLY / PAST
a. / Heat Cramps
b. / Fainting
c. / Heat Exhaustion
d. / Heat Stroke
e. / Other
Yes / No
44. / Have you ever lost consciousness due to extreme heat?
45. / Have you ever had any stress fractures or stress reactions?
46. / Are you pre-occupied with the desire to be thinner?
47. / Have you suffered an injury from being in a motor vehicle accident?
48. / Have you ever been treated for any other behavioral health conditions?

You MUST explain all “YES” answers below:

Head Injury

Yes / No
49. / Have you ever had a head injury (bell rung, concussion, knocked out)?
If yes, how many?
50. / When was your most recent head injury?
51. / Did you lose consciousness as a result of any of your head injuries?
52. / Have you ever been kept out of sports after a concussion?
53. / Have you ever been hospitalized after a head injury?
54. / Have you ever had diagnostic testing done after a head injury?
Check all that apply: X-ray MRI CT Scan Neuropsychological Testing (Impact/Computer Based Testing)

You MUST explain all “YES” answers below:

Orthopedic Injuries

Yes / No
55. / Do you currently have an orthopedic injury that would limit your participation?
56. / Have you ever had a CT scan/MRI/Bone scan?

You MUST explain all “YES” answers below:

57. / Have you ever had an injury to your head?
NEVER / CURRENTLY / PAST
a. / Skull Fracture
b. / Laceration/Cut
c. / Other
58. / Do you suffer from severe headaches or migraines?

You MUST explain all “YES” answers below:

59. / Have you ever had an injury to your eye?
NEVER / CURRENTLY / PAST
a. / Eye Socket Fracture
b. / Black Eye
c. / Eye Disease/Abnormal Vision
d. / Other

You MUST explain all “YES” answers below:

60. / Have you ever had an injury to your nose?
NEVER / CURRENTLY / PAST
a. / Chronic Nose Bleeds
b. / Deviated Septum
c. / Fracture
d. / Other

You MUST explain all “YES” answers below:

61. / Have you ever had an injury to your ear?
NEVER / CURRENTLY / PAST
a. / Cauliflower Ear
b. / Ruptured Ear Drum
c. / Ringing or Loss of Hearing
d. / Other

You MUST explain all “YES” answers below:

60. / Have you ever had an injury to your mouth?
NEVER / CURRENTLY / PAST
a. / Jaw Fracture/TMJ Disorder
b. / Tooth Fracture/Loss of Tooth
d. / Tooth Implants
e. / Other

You MUST explain all “YES” answers below:

61. / Have you ever had an injury to your neck?
NEVER / CURRENTLY / PAST
a. / Cervical Spine Fracture
b. / Stinger/Burner
c. / Whip Lash
d. / Chronic Muscle Spasm
e. / Other
Yes / No
62. / Have you undergone diagnostic imaging on a cervical spine or neck injury?
Check all that apply: X-ray MRI CT Scan

You MUST explain all “YES” answers below:

63. / Have you ever had an injury to your back?
NEVER / CURRENTLY / PAST
a. / Scoliosis
b. / Chronic Back Pain
c. / Numbness/Tingling/Radiating Pain
d. / Other

You MUST explain all “YES” answers below:

64. / Have you had had an injury to your chest or abdomen?
NEVER / CURRENTLY / PAST
a. / Rib Fracture
b. / Abdominal Strain
c. / Spleen Laceration
d. / Chostochondral Sprain/Arthritis
e. / Other

You MUST explain all “YES” answers below:

65. / Have you had any issues with the following organs?
NEVER / CURRENTLY / PAST
a. / Kidneys
b. / Reproductive Organs
c. / Spleen/Liver
d. / Stomach/Intestines
e. / Thyroid
f. / Other

You MUST explain all “YES” answers below:

66. / Have you ever had an injury to your shoulders?
NEVER / CURRENTLY / PAST
a. / Dislocation/ Subluxation
c. / Collar Bone Fracture
d. / AC separation
e. / Impingement
f. / Tendonitis
g. / Burner/ Stinger/Brachial Plexus Injury
h. / Labral Tear
i. / Instability
g. / Other
Yes / No
67. / Have you undergone or been advised to have surgery or an injection for a shoulder injury?

You MUST explain all “YES” answers below:

68. / Have you ever had an injury to your elbows?
NEVER / CURRENTLY / PAST
a. / Fracture
b. / Tendonitis
c. / Other

You MUST explain all “YES” answers below:

69. / Have you ever had an injury to your hands, wrists, or fingers?
NEVER / CURRENTLY / PAST
a. / Finger Deformity
b. / Fracture
c. / Tendonitis
d. / Sprain (Ligaments)
e. / Strain (Muscle/Tendons)
f. / Dislocation
g. / Other

You MUST explain all “YES” answers below:

70. / Have you ever had an injury to your hips or pelvis?
NEVER / CURRENTLY / PAST
a. / Hernia
b. / Hip Pointer
c. / Strain/Pull
d. / Labral tear
e. / Osteitis Pubis/Athletic pubalgia
f. / Other

You MUST explain all “YES” answers below:

71. / Have you ever had an injury to your knees?
NEVER / CURRENTLY / PAST
a. / Ligament Tear (ACL, MCL, PCL, LCL)
b. / Cartilage/Meniscus
c. / Tendonitis (Jumper’s Knee)
d. / Fracture
e. / Patellofemoral Syndrome
f. / Osgood-Schlatter’s Disease
g. / Other

You MUST explain all “YES” answers below:

72. / Have you ever had an injury to your feet or toes?
NEVER / CURRENTLY / PAST
a. / Sprain (Ligaments)
b. / Strain (Muscle)
c. / Fracture
d. / Morton’s Neuroma
e. / Plantar Fasciitis
f. / Flat Feet/High Arches
g. / Other

You MUST explain all “YES” answers below:

73. / Have you ever had an injury to your lower legs?
NEVER / CURRENTLY / PAST
a. / “Shin Splints”
b. / Stress Reaction/Fracture
d. / Compartment Syndrome
e. / Other
74. / Have you ever had an injury to your ankles?
NEVER / CURRENTLY / PAST
a. / Sprain (Ligament)
b. / Strain (Muscle)
c. / Fracture
d. / Instability
e. / Other

You MUST explain all “YES” answers below:

If you have any additional conditions, injuries or concerns not addressed above please use the space below.

I, ______(print name) am eighteen years of age or older (if under 18 years of age, signature of parent or legal guardian is required below). As a condition of eligibility for participation in Fisher College Varsity Athletics, I hereby certify and agree to the following:

Consent to Treat:

• I hereby grant permission for any member of the Fisher College Sports Medicine team (which includes but is not limited to certified athletic trainers and team physicians) to proceed with any needed medical treatment. I understand that medical treatment may include, but is not limited to, the following: preventive measures (e.g. taping, bracing and padding), application of therapeutic modalities, application of ice and heat, rehabilitation exercises for acute, chronic or post-surgical injuries, evaluation of acute or chronic injuries/illness and referrals to other medical professionals.
• I understand that in the case of a medical emergency, the student or parent/guardian understands that every reasonable attempt will be made to communicate with the student directly, or in the case of minors, with the student’s parent or guardian, concerning emergency medical treatment of the student.
• I understand that in the event of the student-athlete’s incapacity, every attempt will be made by the College and/or Sports Medicine team to communicate with the parent, guardian, or other emergency contact. In the event that the above parties cannot be contacted, the Sports Medicine Team is authorized to act on behalf of the student-athlete even though the parent, guardian, or emergency contact cannot be consulted. My consent to treat applies to treatment involving life saving measures considered to be medically necessary.
• I hereby grant permission to the Fisher College Sports Medicine team to discuss any injury/condition with the coaching/administrative staff only as it affects my health and safety during participation in athletics. I give the Fisher College Sports Medicine team permission to obtain and release information concerning injuries/ illness that may impact my health and safety while participating in Fisher College Varsity Athletics.I also, hereby grant permission for any member of the Fisher Sports Medicine team to communicate with Health Services in regards to my general health. In addition, I give permission for Health Services to disclose any medical information as they deem necessary to the Fisher College Sports Medicine team. This permission extends throughout the entire time I am enrolled at Fisher College.

______(Initial Here)

Description of Condition(s)/ Health Status:

• I understand the importance of adequate health and conditioning, which is necessary to decrease my risk of illness, injury, or death arising from my participation in varsity athletics. I further understand that it is my duty to completely and accurately disclose all health-related conditions that may, in any way, affect my ability to participate safely.
• I recognize that the College’s understanding of my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities I have experienced. I hereby affirm that I have fully disclosed in writing my prior medical history, and at the time of my physical examination, my physician informed me that there was no medical reason for prohibiting or restricting my participation in collision, contact, or non-contact sports.

______(Initial Here)

Change in Health Status:

• The information I have provided by to the Sports Medicine team concerning my medical and psychological condition is true and accurate to the best of my knowledge.
• I acknowledge that it is solely my responsibility to inform the Fisher College Sports Medicine team of a change in my physical or psychological condition that might affect or impair my ability to participate in varsity athletics, or be detrimental to my health and safety, or that of fellow participants.

______(Initial Here)

Health Insurance Coverage:

• I agree to provide the Fisher College Sports Medicine team with proof of insurance prior to commencing any conditioning, training, and/or participation in varsity athletics. I understand that it is solely my responsibility to inform the Fisher College Sports Medicine team of any change in my insurance policy or coverage. I acknowledge that my failure to do so will result in termination of my participation privileges.
• I understand that if I sustain an injury while participating in Fisher College Varsity Athletics, any expenses not covered by my primary insurance company may be covered by an excess insurance policy provided by the college only after the primary insurance deductible has been fulfilled and the $50 per injury deductible for the excess insurance has been met. I further understand I must provide Fisher College with the proper documentation demonstrating that the deductible has been met and/or surpassed to initiate the process of additional coverage of medical expenses by the secondary insurance policy.

______(Initial Here)

Student Risk Sharing and Indemnification Agreement:

In consideration for the College permitting me to engage in these sports, which permission the College is not otherwise required to grant, I hereby release Fisher College, its Board of Trustees, officers, agents, employees, volunteers, servants, consultants, affiliates, representatives, successors and assignees from any and all liability arising from any injuries or illness to me, including death and serious bodily injury, which in any way results from my participation in these sports while I am enrolled in or otherwise attending or present at Fisher College.