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Medical history

MEDICAL HISTORY
HANOVER COLLEGE SPORTS MEDICINE
Name___________________________________________________ Date_______________________________ Sport (s)__________________________________ Participation Year: In order to provide quality care it is important that all questions be answered completely. This information will be kept confidential.
Do you have now or have you had in the past problems with the following:
Staff Use Only:

Height__________
Do you have allergies to:
Have you had surgery for:


Females:

Are you taking any medication:


Has any person in your family died before the age of 40?


What relationship were they and list the cause of death:

Brother_________________________ Sister__________________________
Grandparents_______________________________________________________________

List any medication(s) you are currently taking, including the birth control pill:


IF YOU ANSWERED YES IN ANY OF THE ABOVE AREAS PLEASE GIVE DETAILS BELOW. INCLUDE
APPROXIMATE DATE OF PROBLEM.
Answer all of the following questions concerning your medical history. Please include the name of the doctor (if known), the date of the injury, the specifics of the injury, and any other pertinent information (surgery, restrictions, braces, etc.). Have you ever had a head injury? (Bell rung, concussion, etc.) What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a neck injury? (Fractures, What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe shoulder injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe elbow or wrist injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe hand or finger injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe low back or trunk injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe thigh or hip injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe knee injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had a moderate or severe foot or ankle injury? What________________________________________ When________________________________________ Doctor_______________________________________ Comments_________________________________________________________________________ Have you ever had an injury that has caused you to be hospitalized or have surgery? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever worn any type of braces or specialized equipment to protect or prevent an injury? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever had shin splints? Do you have any foot condition we should be aware of? Explain____________________________________________________________________________________________________________________________________________________________________________________ List any fractures/brakes. Include right or left side. Do you have a pin, screw, staple, button or plate somewhere in your body as a result of surgery? List any other information concerning your medical history that the Sports Medicine staff should be aware of? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I verify by my signature below, that the information given is complete and accurate to the best of my knowledge. If the above information changes I am responsible for updating my medical file by contacting the Head Athletic Trainer or Team Physician. ________________________________________________________ INSURANCE QUESTIONNAIRE
The Acknowledgement of Insurance Requirements must be read and understood and this form
completed PRIOR to the student-athlete participating in practice and/or competition.
Student’s Name______________________________________________ Soc.Sec. #_______________________ Sport(s)_________________ Year in School: FR SO JR SR Date of Birth_____________ Gender M F Street Address __________________________________________________ Phone #______________________ City, State and Zip __________________________________ Name_________________________________ Name____________________________________________ Soc.Sec.#_______________________________Soc.Sec.#__________________________________________ Employed: ____Yes ____No Employer______________________________ Employer_____________________________________________ Work Phone ___________________________ Work Phone__________________________________________ Insurance Information
Policy Holder Name ________________________________________________________________ Relationship to Student Athlete ______________________________________________________ Insurance Company Name___________________________________________________________ Insurance Company Address ________________________________________________________ ________________________________________________________ Policy or ID # ____________________ Group # _________________________ Insurance Company Phone # ______________________ Benefit phone # ____________________ Primary Physician Name __________________________Office number _____________________ Is pre-authorization required for non emergency procedures? Does the policy cover athletically-related injuries? I, __________________________________________, attest that I have insurance coverage under
a current, in force insurance policy for injuries that occur during my participation in
intercollegiate athletics. If there is a change in coverage or expiration of coverage, I agree to
notify Hanover College of this development and update the insurance information I have on
file with Hanover College Sports Medicine.
I/WE further agree that all information provided in this document is accurate and complete.
I/WE UNDERSTAND THAT I/WE are responsible for filing all claims associated with
athletic injuries within 3 months of incurring the first bill. I/WE also understand that I am
financially responsible for all uncovered claims.

Student/Athlete ____________________________________________ Date___________________
Parent/Guardian ____________________________________________ Date___________________
(Required if student is under the age 18) CONSENT FOR TREATMENT
In the event of a medical or surgical need for the undersigned student while he or she is a student-athlete at Hanover College, I/we hereby authorize the performance upon said student-athlete of such medical or surgical procedures as may be prescribed by a physician licensed to practice medicine and surgery. STUDENT SIGNATURE ____________________________________________ Date _____________________ PARENT/GUARDIAN SIGNATURE_________________________________ Date ____________________ (Required if student is under the age 18) Acknowledgement of Receipt
I acknowledge receiving a copy of Hanover College's Athletic Injury and
Medical Policy Guidelines. I understand the College's responsibility to a
student who becomes injured as result of participation in intercollegiate
sport. I also understand that the Team Physician or his delegate has
the final say as to participation status.

STUDENT/ATHLETE SIGNATURE_______________________________________________________________ Date_____________ PARENT/GUARDIAN SIGNATURE_________________________________________ Date_____________ (Required if student is under the age 18) YOU MUST INCLUDE A COPY (FRONT AND BACK) OF YOUR CURRENT INSURANCE CARD AND THE COMPLETED EMERGENCY Permission to Release Information
Because of the Health Information Portability and Accountability Act (HIPAA) privacy rule which went into effect April, 14, 2003, we (Hanover College Sportsmedicine) are now required to obtain your permission to release information regarding your care and playing status. In an effort to provide you with the best possible medical coverage, there may be times when your medical information will need to be shared with other
designated medical providers such as: the team physicians, team dentist, team
optometrist, staff physical therapist, staff certified athletic trainers and college
nurse practitioner. NOTE: Release of information to providers outside the
Hanover College network of providers, will require a separate release form.

In addition to the medical providers, your head coach will need to know your capacity to participate in practices and competitions. Since your personal medical information is and will always be considered confidential only the most basic information will be shared with your head coach. However, once this information is release to your coach, it may no longer be protected under HIPAA. I, _________________________ understand the conditions in which my personal medical information will be released and give permission to the Hanover College Sportsmedicine department to release this information to the designated parties involved in my medical care. This authorization is good for the remainder of your Hanover College In addition, I understand that at anytime I can withdraw this blanket release so long as it is done in writing. My refusal to sign or withdrawal of permission will not be grounds for denial of treatment by the Hanover College Sportsmedicine staff. ________________________________ _________ _________________________________________________________ ________________________________ _________

Source: http://www.hanover.edu/docs/athletics/athtrain_history.pdf

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