*Must Be Filled out & Returned

*MUST BE FILLED OUT & RETURNED (4 PAGES) DATE ______

NYACK COLLEGE

ATHLETICS PARTICIPATION
MEDICAL EXAM / /

CELL PHONE # ______

DORM & ROOM # ______

PLEASE PRINT & ANSWER ALL QUESTIONS UNANSWERED QUESTIONS WILL POSTPONE MEDICAL CLEARANCE

FULL NAME-
FIRST MIDDLE LAST / DATE & STATE
OF BIRTH-
SPORT- / COLLEGE
YEAR- FR SO JR SR / SOCIAL SECURITY
NUMBER-
PARENT/GUARDIAN- / HOME
PHONE-
HOME
ADDRESS-
STREET CITY STATE ZIP CODE

PLEASE EXPLAIN WITH DATES ANY “YES” ANSWERS IN THE SPACE PROVIDED

PLEASE PROVIDE DOCTOR NOTES, ESPECIALLY WHEN REQUIRED***

HOSPITALIZATION / YES / NO / EXPLAIN WITH DATES
Have you ever been hospitalized? -What for?
Have you ever had surgery? -What for?
Have you ever been treated in an emergency room/urgent care? -What for?
ALLERGIES/ASTHMA / YES / NO / EXPLAIN WITH DATES
Do you have any allergies? Food &/or Medicine?
Are you taking any medication for your allergies?
Do you have asthma or exercise-induced asthma?
What inhaler(s) are you using?
Do you have any skin problems- itching, rash, hives, severe acne? -Which one?
Are you taking any medication for the skin problem?
CARDIAC HISTORY / YES / NO / EXPLAIN WITH DATES
Have you ever felt dizzy, lightheaded or passed out during or after exercise?
Have you ever had chest pains during exercise?
Do you tire more quickly than your friends?
Have you ever had high blood pressure?
Have you ever had racing of your heart or skipped a beat?
Has anyone in your family died of heart problems before the age of 50?
Has anyone in your family died suddenly while exercising?
Have you ever been told you have a heart murmur?***
Have you ever been seen by a heart specialist (cardiologist)?***
Have you ever had an echo- cardiogram? -EKG? -Which one?***
Please give your Cardiologist name- / Phone Number-
*** COPIES OF ALL REPORTS REQUIRED / Address-
RESPIRATORY HISTORY / YES / NO / EXPLAIN WITH DATES
Do you have a history of asthma or exercise-induced asthma?
Do you have shortness of breath or chest tightness
Have you ever been to an emergency room because of difficulty breathing?
Have you ever used an inhaler (puffer) or had a nebulizer treatment?
Do you currently use an inhaler (puffer) and/or asthma medications?
-What kind?
Do you cough or wheeze or have trouble breathing during exercise?
NEUROLOGICAL HISTORY / YES / NO / EXPLAIN WITH DATES
Do you get frequent headaches?
Have you ever had a head injury?*** -While playing sports?
Have you ever had a spinal cord injury?***
Have you ever had a concussion? -How many?
Have you ever been knocked out, blacked out or unconscious?
Have you ever had headaches, migraines, memory loss, disorientation, mental confusion, &/or double/blurry vision, due to a head injury?-Which ones & Why?
Have you ever had a pinched nerve or a burner?
Have you ever had a seizure/convulsion?***
Have you or do you have any numbness or tingling? -Where?
Please give your Neurologist name- / Phone Number-
*** COPIES OF ALL REPORTS REQUIRED / Address-

PAGE 2

VISION / YES / NO / EXPLAIN WITH DATES
Have you ever had problems with your eyes or vision? -What?
Have you ever had an eye injury? -What? -When?
Do you wear contacts during practice/games? Hard/Soft/Extended Wear?
What is your prescription? R______L______
Do you wear glasses during practice/games? Protective Goggles?
What is your prescription? R______L______
Is your color vision normal? If not, are you color blind?
INTERNAL HISTORY / YES / NO / EXPLAIN WITH DATES
Were you born with all your internal organs intact?
Do you have only one of the 2 (pair) functioning organs-eyes, kidneys, testicles,
ovary, etc? -Which ones?***
Have you ever sustained an injury or illness to any of your vital organs?
Which one- brain, lung, intestines, eye, stomach, kidneys, ears, liver, nose,
spleen, heart, ovaries/uterus(females), testicles(males)***
Do you have any organs not functioning correctly? -Which one?***
Have you ever had loss of or surgery to remove any body organs?
-Which one- gall bladder, spleen, tonsils, etc.***
Please give your Surgeon’s name- / Phone Number-
*** COPIES OF ALL REPORTS REQUIRED / Address-
DENTAL & CORRECTIVE WEAR / YES / NO / EXPLAIN WITH DATES
Have you ever had a tooth knocked out or fractured?
Do you have a dental cap? False teeth? Bridge? -Which one?
Do you wear any special equipment- knee/ankle brace, pads, orthotics?
-Which one
HEAT/COLD & EXERCISE / YES / NO / EXPLAIN WITH DATES
Have you ever had heat or muscle cramps?
Have you ever been dizzy or passed out in the heat? -Which one?
Have you ever had a heat illness- heat exhaustion/heat stroke? -Which one?
Do you have trouble with dehydration?
Have you ever had frostbite or hypothermia?
ORTHOPEDIC HISTORY / YES / NO / EXPLAIN WITH DATES
HAVE YOU INJURED OR CONSULTED WITH A PHYSICIAN ABOUT ANY OF THE FOLLOWING?
***INCLUDE COPIES OF ALL MEDICAL REPORTS- MRI’S, CT SCANS, X-RAYS, DOCTOR NOTES, & CLEARANCE NOTES
PLEASE INDICATE IF YOU HAD SURGERY ON ANY OF THE FOLLOWING AND INDICATE RIGHT OR LEFT WHEN APPLICABLE!
Have you ever had a cortisone injection?
-Reason for? Body Part? Date?
Have you ever had a cast?
-Reason for? Body Part? Date?
Do you have a history of low back pain?
Have you had any sprains/strains, subluxations/dislocations, fractures/breaks, bursitis/tendonitis, muscle tightness/muscle weakness, torn muscles, torn meniscus/cartilage, etc to any body part listed below?
HEAD / BACK / ARM/ELBOW / HIP / HAMSTRING / CALF
NECK / CHEST/RIBS / WRIST / GROIN / KNEE / ANKLE
SHOULDER / ABDOMINAL / HAND/FINGERS / THIGH / SHIN / FOOT

PLEASE EXPLAIN WITH DATES-

MEDICAL HISTORY Please check all that apply and explain in the space provided.
Abnormal bleeding/easy bruising / Eating Disorder / Insulin Dependant / Scoliosis
Anemia / Epilepsy / Kidney Disease/Problem / Seizures
Appendectomy / Frequent Ear Infections / Malaria / Thyroid Disease
Blood Clotting / Frequent Urinary Infections / Measles / Tonsillectomy
Blood Disease / Hearing Loss / Meningitis / Trouble with Circulation
Blood in Urine / Heart Disease / Mononucleosis / Tuberculosis
Cancer / Hepatitis / Pneumonia / Tumor/Cyst
Depression / Hernia / Recent Weight Loss/Gain / Ulcer
Diabetes / Herpes Infection / Scarlet Fever
PLEASE EXPLAIN WITH DATES-

PAGE 3

FAMILY HISTORY Has any blood relative ever had any of the following?
Relation / Disorder / Relation / Disorder
Alcohol or Drug Dependency / Hypertension (High Blood Pressure)
Arthritis / Kidney Disease
Asthma / Marfan’s Syndrome
Blood Disease (Hemophilia, Leukemia) / Stomach Disease (Ulcer, etc)
Cancer / Stroke/Aneurysm
Diabetes / Sudden Death before age 50
Epilepsy/Seizures / Sudden Death While Exercising
Heart Disease / Tuberculosis
MEDICATION & SUPPLEMENTS
Please list all medications/supplements- both those prescribed by a physician and over-the-counter (OTC) you are currently taking.
MEDICATIONVITAMINS/SUPPLEMENT/ENHANCERS, ETC / DOSAGE / FREQUENCY / REASON FOR TAKING
DRUGS & THE ATHLETIC TRAINER-Please initial each line signifying that you understand & will do each of the following:
______It is my responsibility to consult with the ATC before taking any medication (prescription or OTC) or nutritional supplements to be certain it
is not banned by the NCAA.
______Failure to do so risks loss of NCAA- and/or institutional athletic eligibility.
______It is my responsibility to update this form as it becomes necessary and to notify the ATC of any medication that is used
MEDICAL HISTORY / YES / NO / EXPLAIN WITH DATES
Do you have the Sickle Cell Trait?
Do you have Sickle Cell Anemia?
Have you ever been told not to participate in physical activity by a doctor?
Have you ever been treated for any type of mental illness?
-What? -When? -Where? -Medication?
Have you ever been advised to have any surgical procedure?
-What?
Do you have anything you would like to discuss privately with the doctor?
Have you ever been out of the USA? -When & Where?
Is there any reason that you are not able to participate in athletics?

STUDENT ATHLETE CONSENT FOR PARTICIPATION

I, a Nyack College Student Athlete:

1. Understand that injuries are an inherent part of athletics and that participation in sports requires an acceptance of risk of injury, thus there is a risk that I may be injured while playing or practicing in an intercollegiate sport.
2. Understand that these personal injuries include, but not limited to, death, serious neck and spinal injuries, and further that such injury may result in complete or partial paralysis, brain damage, and serious injury or impairment to virtually all internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system and serious injury or impairment to other parts of the body, general health and well-being.
3. Understand that the dangers and risks of playing or practicing to play or participate in any sports or athletic activity may result not only in serious injury, but in a serious impairment of my future capacitates to earn a living, to engage in other business, social and recreational activities and generally, to enjoy life.
4. Understand that I must refrain from practice or play while ill or injured, until cleared by appropriate clinical practitioners’ (Physicians) and/or their designated representative(s) (Certified Athletic Trainer) whether receiving medical treatment or not.
5. Understand that having passed the physical examination does not necessarily mean that I am physically qualified to participate in athletics, but only that the evaluator did not find a medical reason for disqualification from participation.
6. Understand that in an event of an injury, I am to report to the Certified Athletic Trainer and follow the protocol that is given to me until I am told to stop by the Certified Athletic Trainer.
7. Further acknowledge and understand that it is my responsibility to continue to notify the Nyack College Athletic Trainer of any new limitations on my medical condition throughout my enrollment or participation in sports or athletic activities at Nyack College.
8. Further acknowledge and understand that if I refuse or fail to treat and/or rehab my injury, I must get a clearance note from the team physician stating that I am cleared to participate in intercollegiate athletics, before I return to athletics at Nyack College. Knowing that my insurance, the Nyack College student medical insurance and/or the Nyack College athletic insurance may refuse coverage due to my failure to treat my injury, I will be responsible to pay for the medical bill incurred for treatment of the injury by the team physician.
9. Further agree for myself and on behalf of my heirs, personal representative(s) and assigns to defend, hold harmless, indemnify, and release, and forever discharge Nyack College and anyone acting on its behalf from and against any and all claims, demands and actions, or causes of action, on account of damage to personal property, personal injury or death which may result from my participation, or from causes beyond the control of, and without the fault or negligence of Nyack College, and anyone acting on its behalf, during the period of my enrollment or participation as aforesaid.
10. Certify that the answers to the questions above are complete, correct and true.

DATE:______SIGNED:______

NYACK COLLEGEATHLETIC EXAMINATION PAGE 4

NAME- / DATE OF
BIRTH- / SOCIAL
SECURITY #-
ADDRESS:
STREET CITY STATE ZIP CODE
HEIGHT- / WEIGHT- / VISION- / BLOOD
PRESSURE- / HEART
RATE-
GENERAL EXAM / NORMAL / ABNORMAL FINDINGS / IMMUNIZATION RECORDS- Please insert the most recent date(s).
HEAD/SCALP
NECK / DT- (Diphtheria-Tetanus)- Within last 10 years
EYES/EARS
NOSE/MOUTH/THROAT
HEART / TET- (Tetanus)- Most Recent
LUNGS
ABDOMEN
SKIN / TB MANTOUX- (Tuberculosis)
GENITALIA
HERNIA
POLIO-
Which one? / OPV-
(Oral Polio Vaccine)
ORTHOPEDIC EXAM / NORMAL / ABNORMAL FINDINGS
NECK / Injected Polio
Vaccine-
SHOULDER
ARM / MENINGITIS-Strongly Recommended
ELBOW
FOREARM
WRIST / HEPITITIS A-
HANDS/FINGERS
BACK/SCOLIOSIS
HIP / HEPITITIS B-
LEG
KNEES
CALF / MMR-
Measles, Mumps, &
Rubella
You must enter 2 Doses! / Dose 1- at 12 months after
birth or later
ANKLES
FEET/TOES
ARCH
FUNCTIONAL EXAM / NORMAL / ABNORMAL FINDINGS
SPINE ROM / Dose 2-at least 30 days after
first immunization
JUMP
HOP
SQUAT
DUCK WALK
PHYSICIANS COMMENTS-

CLEARANCE- According to the NCAA, your medical clearance must include a cardiovascular, neurological, and musculoskeletal evaluation for athletic participation. This is why you must receive medical clearance from your Doctor and the Team Physician.

MEDICAL DOCTOR CLEARANCE

/

TEAM PHYSICIAN CLEARANCE

NO

CLEARANCE / DIAGNOSIS- /

NO

CLEARANCE / DIAGNOSIS-
RECOMMENDATION- / RECOMMENDATION-
CLEARANCE
WITH RESTRICTIONS / DIAGNOSIS- / CLEARANCE
WITH RESTRICTIONS / DIAGNOSIS-
RECOMMENDATION- / RECOMMENDATION-
FULL CLEARANCENO RESTRICTIONS / FULL CLEARANCENO RESTRICTIONS
I have examined the above student-athlete, included their immunizations and myrecommendations are as above. / I have examined the above student-athlete and my recommendations are as above.
PHYSICIAN’S
SIGNATURE- / PHYSICIAN’S
SIGNATURE-
PLEASE PRINT
PHYSICIAN’S NAME- / DR. THOMAS S. BOTTIGLIERI
ADDRESS- / 500 Grand Ave. Englewood, NJ 07631
PHONE
NUMBER- / DATE- / (212)-305-4565 / DATE-

REMEMBER

IF YOU HAVE HAD ANY SURGERIES, MAJOR ILLNESS’, MAJOR INJURIES, &/OR PHYSICAL CONDITIONS (EXAMPLE ANY SURGERY, HEART MURMUR, RECENT ASTHMA DIAGNOSIS, SEVERE SCOLIOSIS, CHEST PAINS, MULTIPLE CONCUSSIONS, RECENT INJURIES TO BONES OR JOINTS, MENINGITIS, ETC)…

YOU MUST BRING WITH YOU A COPY OF THE DOCTOR’S NOTES STATING WHAT IT IS YOU HAVE &/OR HAD AND A CLEARANCE NOTE STATING YOU ARE

“CLEARED TO PARTICIPATE IN INTERCOLLEGIATE ATHLETICS”

FROM THE DOCTOR THAT TREATED YOU FOR THAT INJURY/ILLNESS/CONDITION (EXAMPLES NEUROLOGIST, CARDIOLOGIST, GYNOCOLOGIST, ORTHOPAEDIST, ETC)

FAILURE TO DO SO WILL RESULT IN YOU SITTING OUT UNTIL THE ATHLETIC TRAINER HAS THIS INFORMATION IN HAND.

PLEASE BRING IT ALL WITH YOU WHEN YOU COME TO COLLEGE IN AUGUST TO AVOID SITTING OUT.

ANY QUESTIONS, PLEASE CALL THE ATHLETIC TRAINER AT (845) 675-4780