Atlantic Armstrong State University Sports Medicine Welcomes You!
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Atlantic Armstrong State University Sports Medicine Welcomes You! Welcome to intercollegiate athletics at Armstrong Atlantic State University. We hope that your time here will be among the best years of your life. The Armstrong Atlantic State University Sports Medicine Staff is here to help make your athletic endeavors enjoyable and safe. It is necessary for you to closely examine the following documents so that you may understand the policies and procedures that are required of you as a student-athlete at Armstrong Atlantic State University. Please read and complete all of the documents that are enclosed. You must have a completed Athlete/Insurance form with your personal insurance information before you are allowed to participate in any athletic activity (including try-outs). A copy (front and back) of your insurance card is mandatory. If you need assistance in finding a valid health insurance plan, please contact the Head Athletic Trainer. Armstrong Atlantic State University’s athletic insurance policy is described in detail in the following pages. If you have any questions or concerns regarding any of the following forms, please contact the Armstrong Atlantic State University Athletic Training Room at (912) 344-2866. Thank you for your assistance in this matter. We look forward to working with you in the future. Sincerely, AASU Sports Medicine Staff St. Joseph’s/Candler Sports Medicine 11935 Abercorn St. Savannah, GA 31419 912-344-2866 912-344-3420 fax Armstrong Atlantic State University Intercollegiate Athletics Pre-Participation Physical Screening Evaluation 
Name:____________________________________________________ Gender: M F Age: _____________ D.O.B. _____/_____/_____ Date of Exam: __________________ History: Please circle yes or no. Explain all Yes answers in the given space below.
Explain all Yes answers: ______________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________ Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking: ________________________________________________________________________________________________________________________________________________________ Do you have any allergies? Yes No If yes, please identify specific allergy:____________________________________________________ Examination: For Doctor’s Use Height: _______’_______” Weight: __________lbs. Blood Pressure: __________/__________ Pulse: ___________bpm Left Eye: __________/__________ Right Eye: __________/___________ Both Eyes: __________/___________
Longitudinal Arch – Circle One: Present Absent Evidence of Marfan’s – Circle One: Present _____________________________________________________________ Absent Sickle Cell Trait: Positive Negative Waived Participation Status: _____________ Full Unlimited Participation in Intercollegiate Athletics _____________ Limitations (Explain) ___________________________________________________________________________________________________________________________________ _____________ Participation withheld until (Explain) _______________________________________________________________________________________________________________ Physician’s Signature: _________________________________________________________________________ Examination Date: _______________________________________ Armstrong Atlantic State University Sports Medicine General Athlete Information – PLEASE PRINT Athlete’s Name: ________________________________________________________________ Sport(s):______________________________ Last First MI Social Security Number: _______________________________________________________ D.O.B: _________/__________/__________ School Address: ________________________________________________________________ Cell Phone: ________-________-_________ ________________________________________________________________ Athletic Year: Fr Soph Jr Sr Parent/Guardian Name: __________________________________________________________________ Parent/Guardian Address: __________________________________________________________________________________________________________ Street City State Zip Parent/G Home Phone: __________-___________-__________ Parent/G Cell Phone: __________-__________-___________ Another Emergency Contact Name: ______________________________________________________ Number:_________-__________-_________ Health Insurance Information – PLEASE PRINT Fill out the following information and provide a legible copy of the insurance card (Front/Back) Name of Insured: ________________________________________________________________ Insured’s SSN: __________-_________-___________ Last First MI Relationship to Athlete: ________________________________________ Insured’s Employer: _________________________________________ Insurance Company: ____________________________________________________________ Insured DOB: ______/______/______ Insurance Co. Address: ______________________________________________________________________________________________________________ Street City State Zip Insurance Co. Phone: _________-__________-__________ Deductible Amt:______________________________________________________ Policy/ Number: _______________________________________________ Group Number: ________________________________________________ I.D. Number: __________________________________________________ Does your insurance plan include prescription medication coverage? ____________Yes _____________No *If you answered yes, which pharmacy can be used (Wal-Mart, Lo-Cost, CVS, etc)? _________________________________ Primary Physician Name: ___________________________________________________ Number: __________-__________-____________ **A COPY OF THE INSURANCE CARD (FRONT AND BACK) MUST BE INCLUDED WITH THIS FORM AND ON FILE IN THE ARMSTRONG ATLANTIC STATE UNIVERSITY ATHLETIC TRAINING ROOM**
Cancer Yes No __________________________________________________ Blood Disease (sickle cell, leukemia, etc) Yes No __________________________________________________ Diabetes Yes No __________________________________________________ Epilepsy Yes No __________________________________________________ Gout Yes No __________________________________________________ Heart Disease Yes No __________________________________________________ Hypertension (high blood pressure) Yes No __________________________________________________ Hemophilia Yes No __________________________________________________ Marfan’s Syndrome Yes No __________________________________________________ Mental Disorders Yes No __________________________________________________ Stroke Yes No __________________________________________________ Tuberculosis Yes No __________________________________________________ Alcohol/Drug Dependency Yes No __________________________________________________ Is your immunization record complete? Yes No General Medical Health History Have you ever had any of the following conditions?
Do you CURRENTLY have any of the following symptoms or problems?
General Medical Health History Continued Drug, Food, and Miscellaneous Agents Please check the appropriate space according to YOUR use of the following substances: Never Rarely Occasionally Frequently Viatmins ________ ________ _________ _________ Diet pills ________ ________ _________ _________ Sleeping pills ________ ________ _________ _________ Laxatives ________ ________ _________ _________ Alcoholic beverages ________ ________ _________ _________ Anti-histamines ________ ________ _________ _________ Anti-inflammatories ________ ________ _________ _________ (i.e. Aleve, Advil, Motrin) Caffeine ________ ________ _________ _________ Tobacco ________ ________ _________ _________ Creatine supplements ________ ________ _________ _________ Metabolic stimulants ________ ________ _________ _________ Nutritional supplements ________ ________ _________ _________ Other products ________ ________ _________ _________
(eyes, ears, kidneys, lungs, ovaries/testes) YES NO If not, which organs were involved? ___________________________________________________________________________________________
(appendix, tonsils, spleen, hernia, etc.) YES NO If yes, please list the reason for surgery, the date, and the physician’s name and address below. ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ Cardiac Have you ever….? Felt dizzy, light headed and/or passed out during/after exercise? YES NO Had chest pain while exercising? YES NO Had heart palpitations or irregular heartbeat? YES NO Been told you have a heart murmur? YES NO Been seen by a heart specialist? YES NO Had an echocardiogram? YES NO Had a heart stress test? YES NO If you answered Yes, to any of the above questions please explain below: ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ If you answered Yes, to any of the above questions have you been cleared for athletics by your heart specialists? Yes No
Do you have written verification of clearance on file in the AASU athletic training room? Yes No
HEAT Have you ever experienced any of the following? Explanation Heat cramps (fluid loss from excessive heat) YES NO ______________________________________________________ Trouble with dehydration (excess fluid loss) YES NO ______________________________________________________ Heat Stroke YES NO ______________________________________________________ Heat intolerance YES NO ______________________________________________________
Have you ever been to an eye doctor? YES NO If yes, date of last exam: ______/_______/________ Do you wear eye-glasses? YES NO Eye doctor’s name: _______________________________ If yes, for reading only? YES NO Do you wear contacts? YES NO Do you wear glasses to participate in athletics? YES NO Do you have normal color vision? YES NO Have you ever had an eye injury? YES NO Do you have a false eye? YES NO If yes, please give details and explain? _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
Do you have a bridge or false tooth? YES NO _____________________________________________________ Fractured (broken) a tooth? YES NO _____________________________________________________ Had a tooth knocked out? YES NO _____________________________________________________ Wear orthodontics appliances? YES NO _____________________________________________________ Wear a mouth protector? YES NO _____________________________________________________ ALLERGIES Are you allergic too…? Aspirin YES NO Tetanus Serum YES NO Codeine YES NO Anesthetics YES NO Penicillin YES NO Novocain YES NO Sulfur Compounds YES NO Cortisone YES NO Anti-inflammatories YES NO Cosmetics YES NO Hay Fever YES NO Any food YES NO Latex YES NO Chalk/lime YES NO Insect bite/sting YES NO Food Allergies YES NO
___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
Unconsciousness Yes No _________________________________________________________________ Concussion Yes No _________________________________________________________________ Headaches Yes No _________________________________________________________________ Burners/Stingers Yes No _________________________________________________________________ Fractures Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Hospitalized Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________
Sprain/Strain Yes No _________________________________________________________________ Disc Injury Yes No _________________________________________________________________ Numbness/weakness Yes No _________________________________________________________________ Fracture Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Hospitalized Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________ SHOUDLER DATE/EXPLANATION Sprain/Strain Yes No _________________________________________________________________ A-C Joint separation Yes No _________________________________________________________________ Dislocation Yes No _________________________________________________________________ Shoulder “slips out of place” Yes No _________________________________________________________________ Tendonitis Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Hospitalized Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________
Sprain/Strain Yes No _________________________________________________________________ Tendonitis Yes No _________________________________________________________________ Bursitis Yes No _________________________________________________________________ Fractures Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________
Sprain/Strain Yes No _________________________________________________________________ Tendonitis Yes No _________________________________________________________________ Fracture Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________ PELVIS/HIP DATE/EXPLANATION Dislocation Yes No _________________________________________________________________ Fracture Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________
Sprained ligaments Yes No _________________________________________________________________ Torn cartilage Yes No _________________________________________________________________ Tendonitis Yes No _________________________________________________________________ Injections/Drainage Yes No _________________________________________________________________ Fracture Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________ ANKLE/FOOT DATE/EXPLANATION Sprain/Strain Yes No _________________________________________________________________ Tendonitis Yes No _________________________________________________________________ Orthotics Yes No _________________________________________________________________ Dislocation Yes No _________________________________________________________________ Stress fracture Yes No _________________________________________________________________ Fracture Yes No _________________________________________________________________ X-rays Yes No _________________________________________________________________ MRIs, CT, Bone Scan Yes No _________________________________________________________________ Surgery Yes No _________________________________________________________________ Other Yes No _________________________________________________________________
Student-athletes are required to have a primary insurance policy. Student-athletes will not be able to participate in any team athletic related function until the Athletic department has a copy of their insurance card on file. Student-athletes will use their own personal insurance with all claims (personal policy limitations vary by insurance company). The primary insurance is usually a group health plan carried by a parent’s/guardian’s workplace. It is your responsibility to ensure that all bills are filed through that primary insurance. We will assist with this task if requested. AASU carries a secondary policy on each student-athlete through Bob McCloskey Insurance. This policy AASUres secondary coverage for injuries to athletes while participating in “intercollegiate sports.” In order for the secondary coverage to apply, the athletic training staff must arrange any medical care used by the athlete. Once the primary insurance benefits are exhausted, the student athlete must obtain an Explanation of Benefits (EOB) form from their insurance company and deliver it to the athletic training staff. Each student-athlete has a $2,000.00 disappearing deductible, which is met through payments by the student-athlete’s primary insurance and out-of-pocket payments made by the parent/guardian. It is possible that you may left with a bill up to $2,000 because your bills did not meet our secondary deductible. Cases that will not be covered by secondary insurance: -off-season injuries -self-referrals to outside physicians -accidents -illnesses -pre-existing conditions not related to a supervised practice or intercollegiate sport 4. Student-athletes are responsible for the purchase of medication (OTC or prescription) either through their primary insurance or out-of-pocket. In extreme cases of need, you son/daughter should communicate with his/her coach, the athletic director, and athletic trainer for other options.
Once the primary insurance benefits are exhausted, the student athlete must obtain an Explanation of Benefits (EOB) form from their insurance company and deliver it to the athletic training staff. The athletic departments’ secondary insurance may be responsible for those remaining expenses not covered by the primary insurance company if all procedures are followed precisely and in a timely manner. It must be noted that each student athlete has a $2,000 deductible with the secondary insurance provider. You may be left with a bill (up to $2,000) if you do not meet the secondary insurance deductible. It should be noted that the athletic department may only cover injuries sustained during Armstrong Atlantic State University Intercollegiate Athletics supervised/authorized practices or games. Also, if a student athlete insurance carrier drops them, it’s the student athlete’s responsibility to notify the sports medicine staff immediately and options for new primary insurance can be determined. If this is not done and the student athlete is injured, AASU will not be responsible for medical bills sustained at time of injury. Additionally, the secondary insurance will only be filed when the student-athlete reports the injury to one of the AASU athletic trainers, is evaluated by the athletic trainer, and is referred by the athletic trainer. Any other circumstances under which injuries may occur will be regarded as non-athletic in nature and are not the responsibility of Armstrong Atlantic State University Athletic Department, nor is it legal for the athletic department to AASUme such responsibility. The AASU Athletic Training Staff will arrange medical appointments for the student-athletes. The Armstrong Atlantic State University Athletic Department nor its insurers will be financially responsible for payment of unauthorized appointments. The National Collegiate Athletic Association has established guidelines for athletic medical expenses, identifying what is permissible and non-permissible for the institution to pay. Armstrong Atlantic State University Athletic Association may finance the following ATHLETIC MEDICAL expenses: -Athletic Medical Insurance -Death/dismemberment insurance for travel with intercollegiate athletics competition and practice -Counseling expenses related to eating disorders -Special individual expenses resulting from a permanent disability that precludes further athletic participation -Expenses for medical treatment as a result of an athletically related injury. -Medication and physical therapy utilized by a student-athlete during the academic year to enable them to participate in intercollegiate athletics
-Student health insurance -Medical, surgical, hospital or physical therapy expenses to treat non-athletic related illness or injury -Medical, surgical, hospital or physical therapy expenses as the result of an injury going to or participating in class (e.g. physical education class) -Routine dental or vision care -AASU’s secondary health insurance policy DOES NOT cover prescription orthotics. Need for this medical device will be handled on a case by case basis. -Purchase of medication (OTC or prescription) If you should have any questions regarding the Armstrong Atlantic State University Athletic Medical Insurance Policy, please call Armstrong Atlantic State University Head Athletic Trainer at (912) 344-2866. SECOND OPINION/REFERAL OUT POLICY Second opinion physician visits, specialists, diagnostic testing and other services (chiropractic, podiatry, massage therapy, physical therapy, etc…) may only be covered by the Armstrong Atlantic State University Athletic Association if referred and approved by the AASU Team Physician and the AASU Athletic Training Staff. Any expenses incurred by the student-athlete without referral from an AASU athletic trainer or AASU Team Physician will be the sole financial responsibility of the student-athlete. I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL EXPENSE INFORMATION. ______________________________________ ______________ Parent Signature (IF under 18) Date
Student-Athlete Signature Date STATEMENT OF INSURANCE UNDERSTANDING I ____________________________ have been informed and understand the limits of personal injury insurance carried on me by the Armstrong Atlantic State University Athletic Department. I understand that it is required of me to provide proof of primary health insurance to the athletic department. The Athletic Department Policy will pick up payments after the $2000 disappearing deductible as been reached. The secondary policy does not cover pre-existing injuries, injuries sustained outside of athletic participation, and general illness. The secondary policy has a cap of $90,000.00 per injury. AASU is also a participant in the NCAA Catastrophic Athletics Injury Insurance Program, this applies for claims above $90,000 within two years of injury. At any time there is a change in my primary insurance I will notify the athletic department of any change that has taken place. Parent ___________________________________ Date______________ Student-Athlete ______________________________________ Date_____________
Participants can and have the responsibility to help reduce the chance of injury. STUDENT-ATHLETES MUST OBEY ALL SAFETY RULES, REPORT ALL ATHLETIC INJURIES TO THE ATHLETIC TRAINERS, FOLLOW A PROPER CONDITIONING PROGRAM, AND INSPECT ALL EQUIPMENT DAILY. By signing this form, you acknowledge that you have read and understand this warning. STUDENT-ATHLETES WHO DO NOT WISH TO ACCEPT THE RISKS DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS PORTION OF THE FORM AND WILL NOT BE ABLE TO PARTICIPATE!
Student-Athlete Printed Name Parent/Guardian Signature ______________________________________________ If under 18 yrs. of age, parent/guardian Student-Athlete Signature MUST SIGN ______________________________________________ Today’s Date Medical Consent-Part II I hereby grant permission to the Armstrong Atlantic State University team physicians and/or the Armstrong Atlantic State University Athletic Training Staff to provide medical care to myself in the event that I become injured while participating in intercollegiate athletics. I understand that any treatment or medical or surgical care that is provided to me will be done only if it is considered medically necessary for my health and well being. ______________________________________________ ___________________________________________________ Student-Athlete Printed Name Parent/Guardian Signature ______________________________________________ If under 18 yrs. of age, parent/guardian Student-Athlete Signature MUST SIGN ______________________________________________ Today’s Date Directory: insideAthletics -> copy of sportsmedicine copy of sportsmedicine -> Gender: m f age: D. O. B Download 249.73 Kb. Share with your friends:
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