LUTHER COLLEGE VARSITY ATHLETIC HEALTH-STATUS QUESTIONNAIRE Participation History – To be completed by the Student Athlete

Students participating in intercollegiate athletics must have a complete physical examination including orthopedic screening. A student-athlete who has

sustained a significant injury or illness within the past 12 months must receive clearance from a physician before resuming participation in a varsity sport.

Name __________________________________________________________ Date of Birth _____/______/______ Year in College: 1 2 3 4

ID Number _____________________________Sport _____________________________________________________________________________

Phone Number: (______) ________ - ____________ Luther Email: __________________________________________________________

Tetanus (must be within 10 years) _________________________ Are you CURRENTLY under the care of a physician for any chronic medical condition? Yes No If yes, please indicate condition and treatment. ____________________________________________________________ Have you ever: date date Passed out during exercise? ……….. Yes No _____________ Had seizure/convulsions? …………………… Yes No __________ Had chest pain during exercise? …… Yes No _____________ Been dizzy during exercise? …………………. Yes No __________ Had a heart attack? ………………………. Yes No _____________ Had a head injury/concussion? …………… Yes No __________ Been told you have a heart murmur? Yes No _____________ Been knocked out? ……………………………….. Yes No __________ Had racing heart/skipping beats? Yes No _____________ Had asthma or wheezing? ……..………. Yes No __________ Had heat exhaustion/heat stroke? Yes No _____________ Use an inhaler before you exercise?........ Yes No __________ Been dizzy or passed out due to heat? … Yes No _____________ Have you been hospitalized or had a surgical operation? Yes No If yes, explain: __________________________________________________________ ______________________________________________________________________________________________________________________________________ Has anyone in your family died from heart problems or died suddenly before age 55? Yes No If yes, explain:_____________________________________ _______________________________________________________________________________________________________________________________________

Do you: Have weakness, pain, or swelling in any of the following? Have high blood pressure? ………………………………………… yes no Y N Y N Y N Y N Tire more quickly than your friends during exercise? … yes no Hand…. Arm…. Back.. Shin/Calf… Smoke cigarettes? (number per day: ____) ……………….. yes no Wrist…. Shoulder Hip.. Ankle………. Use smokeless tobacco? …………………………………………….. yes no Forearm Neck…. Thigh Foot………… Have more than 2 alcoholic drinks per week? ………….. yes no Elbow Chest Knee.. Back……….... Have very irregular or absent periods? …………………….. yes no Have diabetes? …………………………………………………………. yes no Must you use special equipment for completion (pads, braces, neck roll, etc.)? Wear eyeglasses/contact lenses/ protective eyewear? yes no Yes No Are you missing one of any paired organ? (eye, kidney testicle) Yes No If yes, please explain: _________________________________________________ Have you had mononucleosis recently? Yes No If yes, provide date: _____________________________________________________________________ Have you ever or are you currently being treated for any eating disorder? Yes No If Yes, explain:_______________________________________________ Are you now receiving or have you ever received treatment or counseling for mental health illness or substance abuse? Yes No If yes, please explain: ________________________________________________________________________________________________________________ Sickle cell status: positive negative unknown/waived

If Unknown/waived: I have completed the 2nd Education sessions. Yes No

Are you presently taking any medications (birth control, prescriptions meds, vitamins, aspirin, etc.): ________________________________________________________________________________________________________________________ Have you or are you currently taking performance enhancement supplements (creatine, etc): ________________________________________________________________________________________________________________________ Please list any allergies you may have (medicine, bees, food, etc): ________________________________________________________________________________________________________________________ I, the undersigned herewith declare to the best of my knowledge, that the above questions have been answered truthfully and correctly and

A. Understand that I must refrain from practice or play during medical treatment until I am discharged from treatment or given a written permit by the attending physician to resume participation.

B. Understand that having completed the pre-participation screening process does not necessarily mean I am physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify me.

C. Understand that I cannot participate (practice or compete) until this form is signed by a Physician/Physician Assistant D.

Student Athletes Signature ________________________________________________________________________ Date __________________________________

PRE-PARTICIPATION MEDICAL SCREEN TO BE COMPLETED BY PHYSICIAN/PHYSICIAN ASSISTANT

PHYSICAL EXAMINATION Height without Shoes _________________ Weight _____________________ Blood Pressure _____________Pulse_____________ Vision: Corrected lenses Uncorrected Left eye: ___________________ Right eye: _______________________ I have reviewed the medical history with this student-athlete Yes No Is there any medical history or an injury or illness within the past 12 months which might limit full participation in a varsity sport? Yes No If yes, state reason________________________________________________________________________________________________________

TO BE COMPLETED BY PHYSICIAN Normal Abnormal Describe findings, please refer to item number

1. Head ……………………….. ________________________________________________________ 2. Eyes (pupils), ENT………. ________________________________________________________ 3. Teeth ………………………… ________________________________________________________ 4. Chest …………………………. ________________________________________________________ 5. Lungs …………………………. ________________________________________________________ 6. Heart …………………………. ________________________________________________________ 7. Abdomen……………………. ________________________________________________________ 8. Neurologic …………………. ________________________________________________________ 9. Skin …………………………... ________________________________________________________ 10. Physical Maturity ……….. ________________________________________________________

ASSESSMENT Full Sport Participation/Cleared Limited Participation (describe limitations, restrictions) ___________________________________ ________________________________________________________________________________ ________________________________________________________________________________ No Clearance (list reasons) _____________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Recommendations ______________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Physician’s Signature ______________________________________________________Date _____________________ Physician’s Name (printed) ___________________________________________________________________________

Orthopedic Screening Examination Form To be completed by Physician/Physician Assistant/Certified Athletic Trainer

Name Sport

Ankle/Foot: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Laxity/Instability-

Recommendations-

Knee: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Laxity/Instability-

Recommendations-

Hip/Thigh: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Laxity/Instability-

Recommendations-

Low Back: History of Injury- YES NO Please Describe ROM/Flexibility-

Neurovascular-

Recommendations-

Shoulder: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Laxity/Instability-

Recommendations-

Elbow: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Laxity/Instability-

Recommendations-

Wrist/Hand: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Laxity/Instability-

Recommendations-

Cervical Spine: History of Injury- YES NO Please Describe ROM/Flexibility-

Strength-

Neurovascular-

Recommendations-

Other: History of Injury- YES NO Please Describe Head Trauma / Concussion Hx

Recommendations-

Recommendations / Comments:

Status: Pass without restrictions

Pass with restrictions

Further Evaluation Needed- Appt. with

Student-Athlete’s Signature Date

Examining Physician’s or ATC Signature Date Athletic Training Student Initials