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North Park University Intercollegiate Athletics Pre-Participation Packet

For Incoming Student-Athletes

Prior to participating in any practice or competition within North Park University Intercollegiate Athletics, the following Pre-Participation Packet needs to be completed and reviewed by the Athletic Training Staff. Please use the following chart as a checklist to gather all forms prior to your sport’s organized activities for the academic year.

Please read the following statements carefully and then print, sign and date (parent/guardian if under 18). By signing, the student-athlete indicates that he/she understands and accepts these policies and that the student-athlete will not be permitted to participate in any organized activity until he/she has signed this form.

• I understand that my passing a physical examination by a physician does not necessarily mean that I am physically qualified to engage in intercollegiate athletics, but only that the M.D or D.O. did not find a medical reason to disqualify me.

• I understand that, if the physical examination portion of this form is filled out by anyone other than a physician, or if I knowingly include any false information on any part of this form, I will be immediately excluded from participation in intercollegiate athletics at North Park for one calendar year.

Printed Name: __________________________ Signature: ____________________________ Date: ___/___/______

Sport(s) ___________________________ Parent/Guardian (if under 18) ____________________________________

✔ Please check the box to the left when the item has been read/completed! Page 2: Informed Consent for Medical Treatment & Assumption of Risk/Shared

Responsibility: Read, sign and date. (Parent/guardian if under 18). Page 3-4: Student-Athlete Authorization and Consent for Disclosure of Health

Information to North Park University: Read, sign, and date. This allows the medical staff to communicate your condition with each other in addition to relevant NPU personnel (coaches, physicians, specialists, etc.) (Parent/guardian if under 18).

Page 5: North Park University Health Insurance Information: No signature necessary. Important to read about the necessity for health insurance before participating in athletics as well as the North Park University Athletics’ excess policy.

Page 6: Personal/Emergency Contact Information & Disclosure of Health Information to First Agency, Inc.: Fill out completely, including whom to contact in an emergency. Read, Print, Sign, Date. (Parent/guardian if under 18).

Page 7: ADHD Medication Reporting Form: Many medications used to treat ADHD are restricted substances by the NCAA. If this is applicable to you, complete the form & attach documentation from treating physician. If this does not apply to you, leave this form blank.

Page 8: North Park University Athletics Drug Testing Consent Form: North Park has an institutional policy for all student-athletes at North Park University separate from the NCAA. By reading, signing and dating (parent/guardian if under 18) you agree to the policy, which can be found in full in the Student Athlete Handbook at athletics.northpark.edu.

Page 9-10: Sickle Cell Education and Testing Compliance Form: Only for student-athletes new to North Park Intercollegiate Athletics. Read, sign, date and include proof of testing/results if applicable (parent/guardian if under 18).

Page 11: CCIW Injury and Illness Reporting Acknowledgement Form: Only for student-athletes new to North Park Intercollegiate Athletics. Read, sign, and date.

Page 12: Health History Form: Read all sections carefully and complete all requested information. Elaborate upon any “YES” answers in the space provided. After finishing, sign and date at the bottom (parent/guardian if under 18).

Page 13: Physical Examination Form: According to the NCAA guidelines, the Physical Form MUST BE SIGNED BY AN MD or DO. Physicals signed by a Nurse Practitioner (NP), Physician’s Assistant (PA-C), etc. will NOT be accepted.

YOU MUST INCLUDE A COPY OF THE FRONT AND BACK OF ALL CURRENT INSURANCE CARDS. See more information on page 5.

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North Park University Intercollegiate Athletics Department of Athletic Training

Informed Consent for Medical Treatment Form I hereby grant my permission to the North Park University team physicians, athletic training staff, and athletic training students to assess, treat, and rehabilitate any injury that I may suffer as a result of my participation in the North Park University intercollegiate athletic program. I understand that any treatment, medical or surgical care that is provided to me will be done only if it is considered medically necessary for my health. I hereby grant my permission to the North Park University team physicians and athletic training staff to refer me as they deem appropriate to the appropriate medical personnel, to a hospital, or any other medical facility for treatment for any injury or illness that I may suffer as a result of my participation in the North Park University intercollegiate athletic program. Student-Athlete’s Signature: ______________________________ Date: ____/____/____

Parent/Guardian’s Signature: _____________________________ Date: ____/____/____ (If Student-Athlete is under 18 years of age)

North Park University Intercollegiate Athletics Department of Athletic Training

Assumption of Risk and Shared Responsibility Form Participation in intercollegiate athletics involves the inherent risk of injury, the severity of which may range from minor to catastrophic, or from temporary impairment to permanent disability, including paralysis or death. Since the participation in sports requires an acceptance of the risk of injury by the student-athlete, he or she rightfully assumes that reasonable precaution will be taken to minimize the risk of serious injury. Student-athletes have this informed awareness of the risks and share the responsibility for minimizing those risks. Student-athletes must comply with all safety guidelines, inspect their equipment daily, and follow athletic training room rules and procedures; report all physical problems to the athletic training staff and adhere to established injury management guidelines, which include total rehabilitation and reassessments before being released to full participation. Having read the above statement I am aware of the inherent risk of injury involved in athletic participation. Finally, I understand that in accepting the risks associated with athletic participation I will also share the responsibility of minimizing those risks. Student-Athlete’s Signature: _____________________________ Date: ____/____/____ Parent/Guardian’s Signature: ____________________________ Date: ____/____/____ (If Student-Athlete is under 18 years of age)

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STUDENT-ATHLETE AUTHORIZATION AND CONSENT FOR DISCLOSURE OF HEALTH INFORMATION

TO NORTH PARK UNIVERSITY TO STUDENT-ATHLETE: 1. HIPAA Protection and Potential Loss of HIPAA Protection. You understand that information related to your health is protected by federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) and that, under certain circumstances, North Park University may be precluded from disclosing such information without your authorization under HIPAA. You further understand that there is the potential that information disclosed pursuant to this authorization and consent might be re-disclosed by the recipient under circumstances such that the information will no longer protected by HIPAA. 2. Your Authorization to Use and Disclose Certain Health Care Information. By signing this form, you authorize and consent to the use and disclosure of any information, other than psychotherapy counseling notes, whether oral or recorded in any form or medium, relating to: (i) your past, present, or future physical or mental health or condition; or, (ii) any services or supplies related to your past, present, or future physical or mental health or condition, including without limitation (a) any preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, (b) any counseling, service, assessment or procedure with respect to your physical or mental condition or functional status affecting you or the structure or function of your body, (c) any sale or dispensing of a drug, device or equipment to you in accordance with a prescription or otherwise, or (d) any past, present or future financial rights or obligations of any person, entity, organization or governmental body with regard to the forgoing services and supplies. For purposes of this authorization and consent the information described in the preceding sentence is referred to as “Your Health Care Information”. 3. Persons and Groups You Authorize to Use and Disclose Your Health Care Information and Purposes for Which You Authorize Your Health Care Information to be Disclosed. You authorize North Park University and its employed or otherwise affiliated physicians, athletic trainers, student athletic trainers, coaches, health care, and administrative personnel to use, and subject to the following paragraph, disclose Your Health Care Information for any purpose: (i) related to the rendering or delivery of any services or supplies, directly or indirectly, by any person, entity, organization or governmental body in furtherance of any preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, or any counseling, service, assessment or procedure with respect to your physical or mental condition or functional status affecting you or the structure or function of your body; (ii) related to any past present or future financial rights or obligations of any person, entity, organization or governmental body with regard to the foregoing services and supplies; or (iii) related to your eligibility to participate in athletic activities or programs organized, sponsored, or otherwise supported by North Park University. 4. Persons to Whom You Authorize Your Health Care Information to be Disclosed. In furtherance of the purposes described in the preceding paragraph, you authorize North Park University and its employed or otherwise affiliated physicians, athletic trainers, coaches, health care, and administrative personnel to disclose Your Health Care Information to each other and to any person, entity, organization or governmental body that: (i) renders or delivers, or which has or is expected to render or deliver, directly or indirectly, any services or supplies in furtherance of any preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, or any counseling, service, assessment or procedure with respect to your physical or mental condition or functional status affecting you or the structure or function of your body, (ii) has, has had, or may have, any financial rights or obligations with respect to the foregoing services and supplies, or (iii) provides oversight or requires reporting with respect to athletic activities or programs organized, sponsored, or otherwise supported by North Park University.

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STUDENT-ATHLETE AUTHORIZATION AND CONSENT FOR DISCLOSURE OF HEALTH INFORMATION

TO NORTH PARK UNIVERSITY 5. Your Right to Revoke This Authorization and Exceptions to That Right. You understand that, subject to the exceptions contained in this paragraph, you may revoke this authorization and consent at any time by delivering a written revocation to North Park University’s Athletic Director. You understand that no revocation by you will be effective to the extent that North Park University has taken action, or allowed action to be taken on its behalf, in reliance on this authorization and consent. You further understand that, if this authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. 6. Authorization Not a Condition of Treatment. You understand that this authorization and consent is voluntary and not required by North Park University for medical treatment, payment for treatment, enrollment in a health plan or for any benefits that North Park University may, in its sole discretion, offer or extend to you. 7. Expiration. This authorization and consent expires three hundred eighty (380) days after the last date that you participate in any athletic activity or program sponsored by North Park University. 8. Acknowledgement. By signing this authorization and consent you acknowledge that you have read, understand, and agree to the foregoing provisions and that you have received a signed copy of this authorization and consent. Name of student-athlete (print) Date Signature of student-athlete If applicable: ____________________________ ___________________________ Name of legal representative Date Signature of legal representative Please describe the nature of your authority to act on behalf of the above Student-Athlete (e.g. parent, legal-guardian): _____________________________________

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North Park University Insurance Policies & Coverage for Intercollegiate Athletics Injuries can and do occur, and we strive to give our student-athletes the best care possible. Although much of your health care can be provided for through our athletic training facilities and Health Services Department, some medical bills are inevitable (x-ray, lab fees, prescriptions, specialist appointments, surgeries, etc.). Because of this, it is important that we review insurance coverage. As an intercollegiate student-athlete you are covered by an athletic accident insurance plan provided by North Park University. This excess policy provides coverage if you sustain a moderate to severe injury that is a direct result of participating in any official intercollegiate game or practice (excludes pre-existing or overuse injuries). The NCAA prohibits us from providing coverage or paying bills for treatment of any condition that is not sustained during intercollegiate participation. These bills are the student-athlete’s responsibility. The plan provided by North Park via First Agency, Inc., is an excess policy, which means it only covers what your primary insurance does not after a $500 deductible is met. The $500 deductible is a disappearing deductible, which means it can be satisfied by primary insurance payments. For example, if the primary carrier pays at least $500 towards an injury, no deductible is applied. If the student-athlete’s primary insurance pays anything less than $500, the amount is applied to the $500 deductible and the difference will be the responsibility of the student-athlete. In other words, not only are you responsible for all medical bills outside of athletic injuries but you are also responsible for the first $500 of bills incurred from a sports injury. You must also show proof you are covered under a primary care insurance plan. Here are options:

1. Your parents’ policy if you are under 26 years old and are still listed as a dependent, or a spouse’s policy 2. Individual insurance plans available on the market, independent from the Affordable Care Act and Medicaid 3. See if you are eligible for a plan via the Affordable Care Act or Medicaid at www.healthcare.gov or call 1-800-318-

2596.Page specific to college students can be found at www.healthcare.gov/young-adults/college-students/ 4. AIP Insurance has a voluntary plan available for North Park students, find information at www.npusinurance.com 5. If you are an international student you can enroll in an insurance plan thru North Park, call the international office at

773-244-5571 and visit the website at https://www.northpark.edu/Campus-Life-and-Services/International-Student-Services

You must be protected in one of these ways. Student-athletes at North Park are not allowed to participate in any way until your insurance information is on file, including a front/back copy of your insurance card. This copy will allow our Sports Medicine staff to expedite the approval process of certain diagnostic tests if needed (i.e. MRI, specialist, etc.). Lastly, if you are enrolled under a parent’s plan please verify that you will be covered for the entire upcoming academic year. In the past, student-athletes have not realized their eligibility expired in the middle of year and then sustained a moderate or severe injury without primary insurance coverage. This is for your own protection! HMO and Similar Plans If the student-athlete is covered under an HMO plan (or similar policy) from outside of Illinois or Chicagoland area, it is important that you are familiar with your insurance coverage while attending North Park University away from home. These plans often require all non-emergent care be directed through your primary care physician, which can be very difficult if you are far away. Our excess policy provides secondary coverage only if the student-athlete follows the primary plan’s procedures, which means you would have to go home to see your physician for all care or approval for diagnostic testing. We strongly recommend talking with your insurance company to be knowledgeable about your coverage while at North Park. Often times they can make recommendations or changes to your policy to accommodate your time away from home. The following is information about the facilities we primarily use for care, which can be shared with your insurance company and they could possibly pre-approve these providers, which would bypass the need to see your primary care doctor from home. While away from home, you could also list our Medical Director as your primary care physician, if permitted and covered by your plan.

Dr. Poonam Thaker – Medical Director Presence Resurrection Medical Center Family Practice/Sports Medicine 7447 W. Talcott Ave, Suite 182 Chicago, IL 60631 Phone 773.774.8000

Swedish Covenant Hospital Emergency Room/Outpatient Diagnostics 5140 N. California Ave Chicago, IL 60625 Phone 773.878.8200

Claim Procedure If a student-athlete is injured as a direct result of participating in any official intercollegiate activity, any medical bills should be sent to your home address. All services must first be billed to your primary insurance plan. After they determine the amount of coverage they’ll provide, you will be provided with an Explanation of Benefits (EOB), including a remaining balance, if any. Once you have this EOB response for every bill, and there is still a remaining balance, please send a copy of every EOB and itemized bill (HCFA format) via mail, fax, or email to the athletic trainer working with your team. These materials will then be submitted to North Park’s excess policy.

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First Agency, Inc. North Park University 5071 West H Avenue 3225 W Foster Ave, Box 25 Kalamazoo, MI 49009-8501 Chicago, IL 60625

*****PLEASE PROVIDE A COPY OF YOUR INSURANCE CARDS (FRONT & BACK)***** Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays.

If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown). Name of Athlete Sport School ID # (if known) Date of Birth College Address Cell Phone ( ) Home Address Home Phone ( ) City State Zip

FATHER/GUARDIAN INFORMATION MOTHER/GUARDIAN INFORMATION

Father's Name Mother's Name Date of Birth Date of Birth Address Address

Cell Phone

Cell Phone

Employer Employer

AUTHORIZATION - To Permit Use and Disclosure of Health Information

This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to process a claim for benefits. Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction (except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, all information concerning advice, care or treatment provided the patient, employee or deceased named below, including all information relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided to our health division for underwriting or claim servicing and information provided to any affiliated insurance company on previous applications. If this Authorization is for someone other than myself, that individual has given me the authority to act on his/her behalf as explained below. I understand that I have the right to revoke this Authorization, in writing, at any time by sending written notification to my agent or to us at the above address. I understand that a revocation will not be effective to the extent we have relied on the use or disclosure of the protected health information or if my Authorization was obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to the attention of the Claims Supervisor. I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the disclosure of information is necessary to determine the level or validity of the claim payment. I also understand, once information is disclosed to us pursuant to this Authorization, the information will remain protected by First Agency, Inc. in accordance with federal or state law. I understand that I or my authorized representative is entitled to receive a copy of this authorization upon

request. This Authorization is valid from the date signed for the duration of the claim.

Name of Claimant (please print) Name of Authorized Representative, or Next of Kin (please print)

Signature of Claimant (if claimant is 18 or older) Date Signature of Authorized Representative of Next of Kin Date

Relationship of Authorized Representative or Next of Kin to Claimant

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Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment

with Banned Stimulant Medication You may skip this form if you do not take any medication for ADHD or similar disorder.

North Park University governed by the rules and regulations of the NCAA. As a member of the NCAA, student-athletes are subject to drug testing programs set forth by the NCAA in addition to North Park University’s institutional policy. The most common medications used to treat ADHD are Ritalin (methylphenidate) and Adderall (dextroamphetamine and amphetamine), which are restricted under the NCAA class of stimulants. The NCAA and NPU recognize the need for properly diagnosed individuals to use these medications to support their academics and their general health. However, we also recognize banned substances can be harmful to student-athletes and may create an unfair advantage of competition. Therefore, it is required by the NCAA and NPU to have appropriate medical information on file in advance of undergoing drug testing. The intent of this policy is to confirm the student-athlete has undergone a clinical assessment to diagnose ADHD, is being monitored routinely for the use of stimulant medication, and has a current prescription on file in order to be approved for a medical exception to the banned drug policy. Please use this form to assist in obtaining the required documentation supporting medical need for treatment of ADHD with stimulant medication. The athletic training staff will file this information with the rest of the student-athlete’s medical record and it will be produced to the NCAA in the event the student-athlete tests positive for the banned medication. More information can be found at http://www.ncaa.org/health-and-safety/medical-conditions/adhd-and-student-athlete. Other specific questions about this policy can be directed to the Head Athletic Trainer: Eric McQuaid, 773.244.5701 or emcquaid@northpark.edu.

Student-Athlete’s Name: _________________________________________________________________

Date of Birth: ________________________ Contact phone number: (______)_________________

The following items are required from your healthcare provider treating your ADHD: Treating Physician (print name): _____________________________________________________ Specialty: ________________________________________________________________________ Office Address/Phone: ____________________________________________________________________ Physician documentation (letter, medical notes) must include the following information: • Diagnosis, date of last clinical evaluation • Medication(s) and dosage, copy of most recent prescription • Follow-up orders • Written summary of comprehensive clinical evaluation. The evaluation can and should be completed by a

clinician capable of meeting the requirements detailed above.

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North Park University Department of Athletics Drug Education and Testing Program Consent to Policy Form

I __________________________________ certify the following:

(Student-Athlete Name)

1. I have read and understand the North Park University Drug Education and Testing Program (“Program”). I accept all conditions of the Program as a condition for my eligibility to participate in the North Park University Intercollegiate Athletics Program. A copy of the program is located online at www.northpark.edu/athletics under the “Student Athlete Handbook”

2. I understand that selection for testing may be based on random selection, reasonable suspicion

of misuse/abuse, and/or other reasonable cause.

3. I understand that the Program prohibits the use of illegal drugs, or drug abuse in any manner, and that a positive test for banned substances under the Program will result in the sanctions set forth in the Program.

4. I consent to the release of any testing results to an authorized representative as outlined in the

Program for the purposes of determining whether a violation of the Program has occurred. In addition to this consent, I understand that in the event of a positive test I will be required to notify my parent(s)/guardian in the presence of the Director of Athletics and/or their designee.

5. I understand that if I test positive for any banned substance that I will be required to participate

in an evaluation(s) by NPU Counseling services and/or Team Physician.

6. I understand that I will be required to follow any recommendation for follow-up or treatment resulting from an evaluation and any expense occurred from an outside agency will be at my own responsibility.

7. I agree to cooperate in providing consent to any counseling services or agency to release to the

Drug Program Administrator an evaluation and recommendations for follow-up or treatment. Signature of Student-Athlete: __________________________________ Date: ____________ Contact Phone #: ______________________________________________________________ Parent Signature_______________________________________________________________

(Required if under 18 years old)

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North Park University Department of Athletics

Sickle Call Trait Educational Form This form is for athletes new to North Park only. Returners can skip.

What is Sickle Cell?

• Sickle cell trait is an inherited condition involving the oxygen-carrying protein, hemoglobin, in red blood cells • This is a common condition, over three million Americans have sickle cell trait • Most predominant in African Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean,

South and Central American ancestry – however, persons of all races and ancestry may test positive • During intense, sustained exercise the abnormal hemoglobin can cause the blood cells to change shape from

round to quarter-moon shaped, otherwise known as “sickling”

What are the risks? • As red blood cells sickle they become inflexible and sticky, blocking adequate blood flow to the tissues,

organs and muscle • This blockage is associated with a condition known as exertional rhabdomyolysis, which is the breakdown of

oxygen-starved muscle – this can progress to sudden collapse, organ failure and death if mismanaged or mistreated

• Other factors that can increase the risk, or worsen the complications, associated with sickle cell trait include: high heat-humidity, dehydration, altitude, general illness and asthma.

Can student-athletes participate if they have the sickle cell trait? • Having sickle-cell trait does not exclude an athlete from participation, but does require precautions in order to

protect against risks associated

How do I fulfill the Sickle Cell Trait testing requirement? 1. Submit results of previous sickle-cell trait testing 2. Undergo sickle-cell trait testing with physician or through Swedish Covenant Hospital and submit results 3. Sign a waiver acknowledging the risks of not knowing your sickle-cell trait status

You must choose one of these three options before you can compete in any way as a student-athlete at North Park. This includes pre-season and off-season training. More Information from the NCAA: http://www.youtube.com/watch?v=EiEpmZLLcuM&feature=youtu.be http://www.youtube.com/watch?v=lbFWP39tF1A&feature=youtu.be http://www.ncaa.org/wps/wcm/connect/public/NCAA/Health+and+Safety/Sickle+Cell/Sickle+Cell+Landing+Page http://www.ncaa.org/wps/wcm/connect/public/NCAA/Resources/Latest+News/2013/January/DIII+approves+sickle+cell+trait+confirmation+requirement

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North Park University

Department of Athletics Sickle Cell Testing Compliance Form

This form is for athletes new to North Park only. Returners can skip.

Please complete this form and submit in one of the following ways:

• Bring hard-copy proof of your sickle-cell trait status to your sport’s reporting day • Scan and email to Eric McQuaid, Head Athletic Trainer, at emcquaid@northpark.edu • Mail it to:

Eric McQuaid North Park University Athletic Training 3225 W Foster Ave, Box 25 Chicago, IL 60625-4895 After reviewing the North Park Sickle Cell Trait Educational Form and other NCAA Educational Materials, I have chosen the following method to remain in compliance with NCAA Division III regulations regarding sickle-cell trait status and testing: CHECK ONE

� I will provide documentation of my sickle cell trait status from previous testing

� I will undergo sickle-cell testing through my primary care physician or Swedish Covenant Hospital

� I, ________________________________, understand and acknowledge that the NCAA and North Park University Department of Athletics recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, aliments and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to the North Park University Athletic Training Staff. I do not wish to undergo sickle cell trait testing and I voluntarily agree to release, discharge, indemnify, and hold harmless North Park University, its officers, employees, and agents from any and all costs, liabilities, expenses, claims demands, or causes of action on account of any loss or personal injury that might result from my non-compliance with the recommendation of the NCAA and the North Park University Department of Athletics. I have read and signed this document with full knowledge of its significance.

Student-Athlete (print) ____________________________________ Sport: _________________ Student-Athlete (sign) ____________________________________ Date: _________________ Parent/Guardian Signature (if under 18) ________________________ Date _________________

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CCIW Injury and Illness Reporting Acknowledgement Form

This form is for athletes new to North Park only. Returners can skip. I, , acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff of my institution (e.g., team physician, athletic training staff). I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution.

I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion. I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury/concussion to my sports medicine staff.

By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue.

I have read the above and agree that the statements are accurate.

Student-athlete’s name

Signature of student-athlete Date

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North Park University Intercollegiate Athletics Health History Form

Adapted from AAFP, et al. 2010 (Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.)

Note: This form is to be filled out by the student-athlete and parent prior to seeing the physician.

Name: ______________________________ Date of Birth: _______________ Sex: __________ Age: _____ Sport(s): _____________________________

Medications (including supplements): ___________________________________________________ Allergies: ___________________________________

Explain any “YES” answers in the lower right box, in detail. Circle questions you don’t know the answers to. GENERAL QUESTIONS Yes No 34. Have you ever had a head injury or concussion? 1. Has a doctor ever denied or restricted your participation in sports for any reason? 35. Have you ever had a hit or blow to the head that caused

confusion, prolonged headache or memory problems?

2. Do you have any ongoing medical conditions? (asthma, anemia, diabetes, infections, etc.) 36. Do you have a history of seizure disorder?

3. Have you ever spent the night in a hospital? 37. Do you have headaches with exercise?

4. Have you ever had surgery? 38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

HEART HEALTH QUESTIONS ABOUT YOU/YOUR FAMILY Yes No 39. Ever been unable to move your arms/legs after being hit or falling?

5. Have you ever passed out or nearly passed out during or after exercise? 40. Have you ever become ill while exercising in the heat? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 41. Do you get frequent muscle cramps while exercising?

7. Does your heart ever race or skip beats during exercise? 42. Do you or someone in your family have sickle cell trait or disease?

8. Has a doctor ever told you that you have any heart problems? (blood pressure, cholesterol, murmur, infection, etc.) 43. Had any problems with your eyes or vision?

9. Has a doctor ever ordered a test for your heart? (ECG/EKG, echo, etc.) 44. Have you had any eye injuries?

10. Do you get lightheaded or feel more short of breath than expected during exercise? 45. Do you wear glasses or contacts?

11. Have you ever had an unexplained seizure? 46. Do you wear protective eyewear, such as goggles/face shield?

12. Do you get more tired or short of breath more quickly than your friends during exercise? 47. Do you worry about your weight?

13. Has any family member or relative died of heart problems or had an unexpected/unexplained sudden death before age 50? 48. Are you trying to or has anyone recommended that you gain or

lose weight?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

49. Are you on a special diet or do you avoid certain types of foods?

15. Anyone in your family have a heart problem, pacemaker, implanted defibrillator? 50. Have you ever had an eating disorder?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? 51. Do you have any concerns that you would like to discuss with a

doctor?

BONE AND JOINT QUESTIONS Yes No FEMALES ONLY Yes No 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? 52. Have you ever had a menstrual period?

18. Have you ever had any broken or fractured bones or dislocated joints? 53. How old were you when you had your first menstrual period?

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, cast or crutches? 54. How many periods have you had in the last 12 months?

20. Have you ever had a stress fracture? Explain “YES” answers here: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21. Have you ever had an x-ray for neck instability or atlantoaxial instability?

22. Do you regularly use a brace, orthotics, or other assistive device?

23. Do you have a bone, muscle, or joint injury that bothers you?

24. Do any joints become painful, swollen, feel warm, or look red?

25. Do you have any history of arthritis or connective tissues disease?

MEDICAL QUESTIONS Yes No 26. Do you cough, wheeze, or have difficulty breathing during or after exercise?

27. Have you ever used an inhaler or taken asthma medicine?

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle, your spleen or any other organ?

30. Do you have groin pain/painful bulge?

31. Have you had infections mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of Student-Athlete _______________________________________________________________ Date ____/____/________ Signature of Parent/Guardian (if student-athlete under 18) __________________________________________________________________

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North Park University Intercollegiate Athletics Physical Examination Form Adapted from AAFP, et al. 2010 (Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.)

THIS EXAMINATION MUST BE COMPLETED BY AN M.D OR D.O!

No PA-C, NP, CNS, or other clinician per NCAA rule

Student-Athlete Name ________________________________ Date of Birth ___/___/______ Sport(s) __________________ Height ________ Weight ________ Male / Female Blood Pressure ________ Heart Rate ________ Vision R 20/ ____ L 20/ ____ Body Fat % (optional): ________ Pupils: EQUAL UNEQUAL Corrected Vision? YES NO

MEDICAL NORMAL ABNORMAL FINDINGS Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitourinary (males only) Skin Neurologic MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand/Fingers Hip/Thigh Knee Leg/Ankle Foot/Toes Functional

�Cleared for all sports without restriction

�Cleared for all sports without restriction with recommendations for further evaluation or treatment for

_____________________________________________________________________________________________

�Not cleared �Pending further evaluation �For any sports �For certain sports ________________________________________

Reason __________________________________________________________________________________________

Recommendations _________________________________________________________________________________ I have examined the above-named student and completed the preparticipation physical evaluations. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the school and the athlete (and parents/guardian if athlete is under 18 years of age). If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardian if athlete is under 18 years of age).

Name of Physician (print) ________________________________________________ Date ___/___/______

Signature of Physician ________________________________________________ MD or DO (circle)

Address ___________________________________________________________ Phone _____________________