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 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: __________/___________ Urinalysis Results: _______________________________
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/Contract 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** Athletic Department Policies 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 assures 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 assume such responsibility. The AASU Athletic Training Staff will arrange medical appointments for the student-athletes. Neither 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/REFERRAL 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 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 Authorization to Release Information-Part IIII hereby authorize and request AASU and St. Joseph’s/Candler athletic trainers and/or their consulting physician(s) to furnish any and all requested information to St. Joseph’s/Candler and/or Optim Health, P.C. physicians, University coaches and administration, professional teams, their agents, scouts, or athletic trainers which directly pertains to my athletic participation in athletics at AASU. Said authorization shall include, but is not limited to: information concerning my physical condition, illnesses, injuries, treatments, hospitalizations, examinations, X-rays, or other forms of diagnostic testing. I hereby fully discharge all parties to whom this authorization extends from any and all penalties of breach student-athlete confidentiality. This authorization period is effective until I am no longer an active athlete at AASU. Additionally, I understand that an additional release form may be required to release information to outside entities in the event that an injury occurs outside of Savannah, Georgia. ______________________________________________ ____________________________________________________ Student-Athlete Printed Name Parent/Guardian Signature _______________________________________________________ If under 18 yrs. of age, parent/guardian Student-Athlete Signature MUST SIGN ______________________________________________ Today’s Date Concussion and Injury Reporting Agreement Form NCAA regulations require all varsity student-athletes to be aware of what a concussion is, as well as signs and symptoms of concussion. Please read the below information and sign and date the bottom of the form to be in compliance with NCAA regulations. What is a concussion? A concussion is a type of brain injury caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be mild bump or blow to the head can be serious. Symptoms are unique for each athlete and this injury requires medical attention and monitoring. Concussions can occur in any sport or recreation activity. Signs and Symptoms of a concussion:
If you think you may have a concussion Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life. I, (please print) _______________________________________ do hereby agree to accept the responsibility for reporting all injuries and illness to the Armstrong Atlantic State University Sports Medicine Staff, including signs and symptoms of concussion. Signature of Athlete________________________________________ Date_______________ Sport(s) ______________________________________________________ Request parent/guardian signature if student-athlete is under 18 years old Parent/Guardian Signature__________________________________ Date________________ The Armstrong Atlantic State Athletic Department Consent to Drug Test and Authorization for Release of Information I hereby acknowledge receipt of a copy of the Armstrong Atlantic State Department reasonable suspicion and voluntary drug testing program for student-athletes. I further acknowledge that I have read this policy and fully understand its provisions. It is my understanding that signing this consent form and returning it is a prerequisite to becoming a member of the intercollegiate team at Armstrong Atlantic State. I further understand that I may refuse to sign this consent form, but as a consequence, I must forego participation in intercollegiate sports at the University. I am aware that I am expected to abide by team rules, that such rules are subject to change, and that I may be dismissed from the team and/or deprived of my grant-in-aid or scholarship for failure to abide by such rules. I acknowledge my understanding that the use or abuse of drugs not prescribed by a physician for a specific medical condition is a violation of team rules. I hereby consent to have samples of my urine collected and tested for the presence of certain drugs or substances in accordance with the provision of the Armstrong Atlantic State Drug Testing Program. I further authorize the Team Physician at Armstrong Atlantic State to make a confidential release to the head coach of any intercollegiate sports in which I am a team member, the Athletic Director at Armstrong Atlantic State and, if a minor, my parent(s) or legal guardian(s), all information and records, including test results you may have relating to the screening or testing of my urine sample(s) in accordance with the provision of the Armstrong Atlantic State Drug Testing Program which is applicable to all intercollegiate athletes at Armstrong Atlantic State. To the extent set forth in this document, I waive any privilege I may have in connection with such information. I further agree that, in the event the results of my drug screening test are positive, I will follow the procedures stated in the section of the policy entitled “Positive Test Results” Armstrong Atlantic State, its Board of Trustees, its officers, employees and agents are hereby released from legal responsibility or liability for the release of such information and records as authorized by this form. Parent’s Signature ____________________________________ (if student-athlete is under 18)
The Undersign (Athlete, Parent/Guardian) herewith, Understands that any medical expense incurred due to the above pre-existing conditions and not directly attributed to athletic participation at Armstrong Atlantic State University is his/her personal responsibility. Understands that the athletic medical insurance is secondary coverage and does not cover him/her until he/she has been cleared by an athletic pre-participation physical examination. Understands that it is his/her responsibility to report all injuries/illnesses to his/her staff certified athletic trainer as soon as possible. Understands that he/she must refrain from practice(s), and/or game(s), per direction of staff certified athletic trainers and/or physician orders, until he/she is discharged or given permission by staff certified athletic trainer to restart participation despite continuation of treatment. Understands that having passed the pre-participation physical examination does not necessarily mean he/she is physically qualified to engage in athletics, but only that the evaluator(s) did not find a medical reason to disqualify him/her at said time of evaluation. Understands that the athlete will not be allowed to participate in any intercollegiate athletics until all forms are complete. Certifies that the above answers are correct and true. ______________________________________________________ _____________________________ Athlete’s Printed Name Date
______________________________________________________ Athlete’s Signature _____________________________________________________ _____________________________ Parent/Guardian Printed Name Date (if Athlete under age of 18) _____________________________________________________ Parent/Guardian Signature (if Athlete under age of 18)
____________________________________________________ _____________________________ Staff Certified Athletic Trainer Signature Directory: insideAthletics -> copy of sportsmedicine copy of sportsmedicine -> Atlantic Armstrong State University Sports Medicine Welcomes You! Download 144.76 Kb. Share with your friends:
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