Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet

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Returning Student-Athlete Physical Packet

Attention: Returning Student-Athletes

On Behalf of the Sports Medicine Department, we look forward to another healthy year

with Academy of Art University Athletics! All Student-Athletes participating in

intercollegiate athletics at Academy of Art University are required to have a current sport

physical prior to participating in any physical activity relating to his/her respective sport.

The purpose of the sport physical is to keep you, the student-athlete, medically safe and to

rule out and correct any dysfunctions that may hinder you from performing to the best of

your ability. The sport physical must be signed and medically cleared by a board

certified medical physician prior to participation in intercollegiate athletics. Personnel

other than a medical physician will not be accepted as valid clearance for participation in

sports. Chiropractors, physical therapists, etc. are not medical physicians and cannot

medically clear student-athletes for participation in intercollegiate athletics at

Academy of Art University.

Please fill out the following packet from pages 3-9 prior to arriving on your scheduled

physical date. If you should choose to have a sport physical done with your own physician,

please have him/her fill out page 2.

Please bring the following materials to your scheduled physical date:

1) This physical packet.

2) Primary health insurance card.

3) Student ID/Driver’s License/Valid form of ID.

The Sports Medicine Department must have this completed packet prior to any

participation in athletics. Please contact us with any questions.

Thank you,

Academy of Art University Sports Medicine Department

Academy of Art University Sports Medicine 79 New Montgomery St. San Francisco, CA 94105

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Academy of Art University - Sports Medicine

Pre-participation Physical Evaluation

Name: _________________________________ Date of Birth: _______________ Sport: ________________________

Height: __________ Weight: __________ % Body fat (Optional): ________ Vision: L: ____/____ R: ____/____

Pulse: ___________ Blood pressure: _____/_____ Vision: Corrected Not Corrected

Normal Abnormal Findings Initials*

MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen

Genitalia (males only)

Skin MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot CLEARANCE

Cleared Cleared after completing evaluation/rehabilitation for:

______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Not cleared for: ______________________________________ Reason: __________________________________________________

Recommendations:

_________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Signature of Physician: ________________________________________ M.D. or D.O. Date: _________________ Name of Physician (print): _____________________________________

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Academy of Art University - Sports Medicine

Returning Student-Athlete Medical History Questionnaire

The information contained in this medical history form will only be used by the Academy of Art Sports Medicine Staff for the purposes of determining if you pose a health threat/risk to yourself on the athletic field. All of the following information will remain CONFIDENTIAL at all times and will not be shared with parents or coaches.

Year of Eligibility: FR SO JR SR Redshirt Date: ________________________

Name: _________________________________ AAU ID#: __________________ Sport: ________________________

Date of Birth: ____/____/______ Age: ______ Gender: ______

Since Your Last Physical Examination: (Please indicate if you have sustained any injuries to said body parts in the past 12 months.)

HEAD

YES

NO

LEFT

RIGHT Describe

NECK

YES

NO

LEFT

RIGHT Describe

SHOULDER 

YES

NO

LEFT

RIGHT Describe

ARM

YES

NO

LEFT

RIGHT Describe

ELBOW

YES

NO

LEFT

RIGHT Describe

FOREARM

YES

NO

LEFT

RIGHT Describe

WRIST

YES

NO

LEFT

RIGHT Describe

HAND

YES

NO

LEFT

RIGHT Describe

FINGERS

YES

NO

LEFT

RIGHT Describe

CHEST

YES

NO

LEFT

RIGHT Describe

SPINE

YES

NO

LEFT

RIGHT Describe

ABDOMEN 

YES

NO

LEFT

RIGHT Describe

PELVIS

YES

NO

LEFT

RIGHT Describe

HIP

YES

NO

LEFT

RIGHT Describe

THIGH

YES

NO

LEFT

RIGHT Describe

KNEE

YES

NO

LEFT

RIGHT Describe

LEG

YES

NO

LEFT

RIGHT Describe

ANKLE

YES

NO

LEFT

RIGHT Describe

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1) Yes  No  Have you been hospitalized or had surgery?

2) Yes  No  Are you presently taking any medications? (If yes, please list below.)

3) Yes  No  Have you experienced dizziness, light headedness, passing out, chest pain, difficulty breathing during or after exercise?

4) Yes  No  Has anyone in your family died of heart problems or sudden death in the past year? 5) Yes  No  Have you had a head injury or knocked out/unconscious?

6) Yes  No  Have you had a seizure?

7) Yes  No  Have you had heat/muscle cramps or been dizzy or passed out in the heat? 8) Yes  No  Do you use special equipment (pads, brace, mouth guard, eye guard, etc.)?

9) Yes  No  Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)? 10) Yes  No  Have you had a drug or alcohol problem?

11) Yes  No  Have you had an eating disorder?

12) Yes  No  Have there been any changes to your menstrual cycle since your last physical? (Women Only)

If you have answered YES to any of the questions above, please list and explain:

 _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________  _______________________________________________________________________________________________

I, the undersigned, hereby acknowledge, affirm, and represent that all statements on this medical

form are complete, true and accurate to the best of my knowledge; and that no answers or

information have been withheld. If any information and/or statements are false and/or have been

omitted in reference to my past and/or present history, I fully understand that Academy of Art

University, its agents, servants, trustees, and employees disclaim liability, and will not be held liable

for any injuries and/or illnesses not noted. I also understand it is my responsibility to keep the

Sports Medicine Staff up to date on my medical status and health or medication changes.

____________________________________________ ______________________

Student-Athlete’s Signature Date

____________________________________________

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Academy of Art University - Sports Medicine

Contact & Health Insurance Information

Name: ___________________________ Sport: ___________________________ Student ID #: ______________________

Date of Birth: ____/_____/______ Age: _____ Sex: ______ Email: ________________________________________

College Address: __________________________________________ ___________________ _______ ________

STREET CITY STATE ZIP CODE

Home Address: ___________________________________________ ___________________ ________ ________

STREET CITY STATE ZIP CODE

Home Phone: ______________________________ Cell Phone: _______________________________

Primary Emergency Contact:

Name: __________________________________________ Relationship: ____________________________

Home Phone: ______________________________ Cell Phone: ______________________________

Secondary Emergency Contact:

Name: __________________________________________ Relationship: ____________________________

Home Phone: ______________________________ Cell Phone: ______________________________

Primary Insurance Information: Insurance Co.: _____________________________________________

Address: ________________________________________________________ Insurance Co. Phone #: ________________

Policy/ID #: ______________________________________ Group #: __________________________________________

Policy Holder Name: ____________________________ DOB: __________________ SSN: ______________________

Type of Insurance: HMO PPO Other: _____________

Primary Care Physician: _______________________________ Physician’s Phone #: _______________________________ Is pre-authorization necessary for diagnostic medical services: Yes No If yes, Phone #: __________________________

Secondary Insurance Information: Insurance Co.: ______________________________________

Address: ________________________________________________________ Insurance Co. Phone #: ________________

Policy/ID #: ______________________________________ Group #: __________________________________________

Policy Holder Name: ____________________________ DOB: __________________ SSN: ______________________

Type of Insurance: HMO PPO Other: _____________

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 The Academy of Art University Department of Intercollegiate Athletics’ accident policy provides insurance for student-athletes with injuries occurring only when participating in the play or practice of intercollegiate athletics. This accident policy is considered “EXCESS or SECONDARY to any other collectible group insurance benefits. Therefore, any claims for benefits must first be field with the group insurance company providing coverage. Only after all available benefits have been exhausted will the Academy of Art University Department of Intercollegiate Athletics’ insurance carrier consider payment for any remaining balances.

 I, hereby, authorize the Academy of Art Department of Intercollegiate Athletics, affiliated hospitals & physicians, to furnish information to insurance carriers concerning any illness, injury & treatments, and I hereby assign to the party all payments for medical services rendered to the student-athlete.

 I agree to supply any and all information requested by my primary insurance, the Academy of Art University Department of Intercollegiate Athletics and their excess insurance in a timely manner.

 A photocopy of this authorization shall be deemed as effective and valid as the original.

 I agree to notify the Academy of Art University Sports Medicine Department immediately upon any change in the above health insurance information. If I fail to do so, I fully understand that I may be responsible for any and all charges incurred.  I hereby certify that I have read and understand the above statements, that any and all questions have been answered to my

satisfaction, and that the answers provided are true, complete and correct to the best of my knowledge.

_______________________________________ _____________________

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Academy of Art University Sports Medicine

Medical Procedures and Insurance Policies

The Academy of Art University Athletic Program carries an excess accidental insurance policy. This means the policy will cover cost not paid by the student-athletes’ or student-athletes’ parents’ primary insurance.

 Student-athletes will be covered by the accidental insurance only if they complete a physical exam and provide proof of

primary health insurance and a completed insurance information form.

 No individual may practice or compete without proof of primary health insurance, obtaining participation clearance from the Team Physician and completion of these forms. If this is not done, insurance coverage cannot be provided and medical care cannot be given. A PHYSICAL FROM AN OUTSIDE PHYSICIAN IS NOT ACCEPTABLE UNLESS APPROVED BY THE HEAD ATHLETIC TRAINER OR AN ASSOCIATE ATHLETIC DIRECTOR.

 Benefits are limited to injuries sustained during participation in regularly schedule and supervised team activities. Coverage includes participation in actual games, practices, scrimmages, strength and conditioning workouts, or while in transit from the Campus to another institution with the Team.

 The Academy of Art University athletic health insurance only provides secondary coverage. This means that your own or your parent’s health insurance policy will take precedence when paying medical expenses. Any medical expenses not covered by the insurance company will be the athlete’s responsibility.

 Any student-athlete with a pre-existing or recurring (i.e. an injury that occurred prior to participation at this institution) injury will not be covered by the athletic insurance unless the particular injury has been cleared by the team physician and recorded as stable.

 The Head Athletic Trainer administers athletic insurance claims and medical referrals.

 The insurance provided by the Athletic Department will not cover any illness or incident unrelated to athletics. Student medical insurance can be purchased through the Academy of Art University Health Insurance Program. This coverage can be purchased by the semester or for an entire school year. This coverage is recommended and required for student-athletes who are without any medical insurance. Please enroll and purchase at https://studentinsurance.wellsfargo.com/enroll/schools.aspx  Any injury or condition that will affect an athlete’s participation in team practice or competition must be reported to the

Athletic Trainer before referral to the Team Physician.

 No individual will be permitted to return to practice or competition after a significant injury without the consent of the Team Physician or Athletic Trainer.

 All injuries must be reported to the Athletic Trainer. Under no circumstances should an athlete seek outside care without proper referral by the Team Physician or Staff Athletic Trainer. If a student-athlete seeks outside medical care without an appropriate referral, THEY WILL BE RESPONSIBLE FOR ALL RELATED MEDICAL EXPENSES. No liability on the part of the Academy of Art University exists or may be assumed to exist for off-campus medical or dental treatment or hospitalization of any kind of athletic injuries without prior referral.

 Primary medical insurance: This is coverage arranged by you, a parent, spouse or employer. Typically classified as a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO). HMO’s are affordable and convenient; however, severely limit the medical service required by a competing athlete. Delays may affect ability to complete or be ready for a season. Recommended coverage involves insuring through a plan that allows for a physician of choice to be seen when required. If coverage is through a HMO, the primary care physician should be located close to campus.

 Medical bills: Please take all medical bills and corresponding Explanation of Benefits (EOB) to the Head Athletic Trainer. The Head Athletic Trainer will send the bill and EOB to the Athletic Department’s insurance company for payment. Please contact the Head Athletic Trainer if there are any further questions regarding medical bills or insurance coverage.

I have read the entire contents of the “Medical Procedures and Insurance Policies” form and understand all of the statements outlined. I understand that my signature below means that I accept the “Academy of Art University Medical Procedures and Insurance Policies.”

_______________________________________ __________________

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Academy of Art University Athletics

Authorization to Release Medical Information

I,______________________________, hereby authorize the Physicians, Athletic Trainers, Sports Medicine Staff, and other health care personnel representing the Academy of Art University Sports Medicine Department to release information regarding my protected health information and any related information regarding any injury or illness during my training for and participation in intercollegiate athletics.

This information may include:

 All medical records and information as requested by authorized parties.

 Information concerning my medical status, medical condition, injuries, prognosis, diagnosis and other related personally identifiable health information, including injury reports, diagnostic test results, progress reports and any other documentation regarding my health status.

Authorized parties that this information may be released to include:

 My parents, legal guardian, and/or spouse for the purpose of assisting me in making healthcare decisions

 The Academy of Art University Sports Medicine staff, team physicians, and coaching staff so that they may make informed decisions concerning my ability and suitability to compete

 My teammates so that they may be made aware of my limitations

 The media, including specifically the Academy of Art University Sports Information Department, to advise the print, radio, and television and other media of this nature, the prognosis and treatment concerning my medical condition of any injuries or illnesses for the purpose of reporting

 The Academy of Art University Athletic support departments, the PacWest Conference and the National Collegiate Athletic Association for reasonable purposes deemed necessary

I understand that my protected health information is protected by federal regulations under either the Health Information Portability and Accountability Act (HIPAA) and the Family Education Rights and Privacy Act of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that my signing of this authorization/consent is voluntary and refusal will not affect my ability to obtain treatment or payment and authorization/consent is not contingent in order to be eligible for participation in NCAA athletics.

This authorization/consent expires 380 days from the date of my signature below, but I have the right to revoke it in writing at any time by sending a dated and signed letter/notification to the Academy of Art University Sports Medicine Department.

___________________________________

____________________

Student-Athlete’s Signature Date

__________________________________________ ________________________

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Authorization and Consent Forms

Name: ________________________________

Student ID#: ____________________________

Medical Consent and Assumption of Risk

I hereby authorize the Academy of Art University Athletics, its Sports Medicine Staff, Team Physicians, and referred physicians to render aid, treatment, medical or surgical care deemed necessary to my health and safety.

I fully authorize the Sports Medicine Staff under the direct supervision of the Team Physicians at the Academy of Art University or institution where a visiting event or match is taking place, to render any first aid, preventative and rehabilitative or emergency treatment deemed reasonably necessary to protect my health and safety.

I additionally grant, when necessary for protecting my health and safety, permission for hospitalization for injury or illness, and treatment or surgery at a competent and accredited facility.

I realize and am aware that there are certain risks as a result of athletic participation. These risks include a full range of injury from minor to catastrophic. I recognize that possible injuries include by are not limited to: strains, sprains, contusions, fractures, brain damage, spinal cord injury, quadriplegia (paralysis of all four limbs), paraplegia (paralysis of two limbs, usually legs), fractured (broken) neck , fractured (broken) back, death, paralysis, or other serious permanent disability can result from my participation in this athletic program. I further realize that the protective equipment, safety rules, coaching instruction, or the medical care I receive will not all guarantee my safety or prevent all injuries I might sustain. Therefore, I release Academy of Art University, its athletic trainers, coaches, and employees from liability for any and all damages or injuries sustained as a result of my athletic participation.

I, the undersigned understand that for any injury or illness requiring medical attention resulting in a missed practice or game, permission by the team physician or athletic trainer must be given in order to resume practice or play games.

The medical information given is complete with my permission receiving stated medical care. I also assume the stated medical risks of injury related to my athletic participation at Academy of Art University.

_______________________________________ _______________________

Student-Athlete’s Signature Date

Authorization to Hold and Carry Prescription Medication

I authorize the Academy of Art University Sports Medicine Staff to hold and carry epinephrine injectors (epi-pens), asthma inhalers, and/or any prescribed medication during practices and games. Student-Athletes are encouraged to carry these items on their own. The Academy of Art Sports Medicine Staff will not, unless in emergency situations, administer prescription medications.

_______________________________________ _________________________

Student-Athlete’s Signature Date

Waiver and Release Regarding Body Piercing

I hereby agree not to file claims or lawsuits against the Academy of Art University or the Department of Intercollegiate Athletics on account of injuries to myself or other(s) that were caused by or made more serious by my body piercing(s) and/or body piercing jewelry. By signing below, I acknowledge that I have read and understood the team rules that apply to my particular sport. I know and understand which item(s) I am expected to remove before practices and competitions. I also understand that the medical staff of the Department of Intercollegiate Athletics strongly recommends that I remove all body piercing jewelry during every practice and competition whether or not mandated by team rules. I take full responsibility for my body piercing(s) and/or body piercing jewelry that I wear, and I also take full responsibility for any injuries or other problems that might occur to me or others as a result of them. I also understand if injury should occur to me or other(s) as a result of my body piercing(s) and/or body piercing jewelry, I take full responsibility of any medical expenses that might occur as a result of injury.

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