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Microsoft word - returning medical forms (2).doc


Dear Student-Athlete/Parent/Guardian,
Please review all the forms in this packet. Each of the form contains information important to the student-
athlete. Forms are located on the front and back of each page. Please complete, sign and date each form.
Please return forms to MSU-Northern Athletic Training only!
Please review the forms for completeness. Incomplete forms or information found to be incomplete are
unacceptable. Student-Athletes will not be allowed to practice or compete, nor receive any evaluation or
treatment, until all the information is provided.
PLEASE HAVE THE FOLLOWING FORMS COMPLETED AND RETURNED BY
AUGUST 1, 2012
ALL STUDENT-ATHLETES:
A. Assumption of Risk
B. Buckley Amendment
C. Drug Testing Consent
D. General Physical Examination (completed by family MD, DO, PA, NP only)
Physical examinations from chiropractors will not be accepted.
E. Insurance Notification
F. Insurance Travel Form
G. Medical History Forms
H. Permission to Provide Medical Treatment
I. Permission to Share Medical Information
J. Xerox Copy of Health Insurance Card (Front & Back)

Please address any of your questions to: MSU-Northern Athletic Training – 406-265-3593 Thank you for your cooperation! RETURNERS MEDICAL HISTORY FORM
Name:______________________________________________________ Today’s Date:____/____/____ Last First Middle SSN: _____-____-_____ Birthday: ____/____/_____ Sport(s): ____________________ Year in College: Fr. So. Jr. Sr. 5yr Sr. Height: _____ Weight: _____ Father’s Name: ______________________________ Father’s Work Phone Number: ( )________________ Mother’s Name: _____________________________ Mother’s Work Phone Number: ( )_________________ Permanent Address (Home): ____________________________________________________________ School Address & Cell Phone # _______________________________________(___)______________ Allergies to Medications: _________________________________________________________________ Medications are you are currently taking: ____________________________________________________ ______________________________________________________________________________________ For your benefit, be as complete as possible. Please include all information pertinent to your medical history. This information will be kept in your confidential medical file. Please write below, in detail, any injuries or general medical disorders that have occurred to you over the months of May, June, July and August. If nothing has occurred, please put NA in the area below. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Pre-participation Physical Evaluation (Dr. portion)
Patient’s name: _____________________________ 1. BP_______ 3. Musculoskeletal Exam Record-laxity, weakness, instability, decreased ROM- if abnormal Other orthopedic problems ____________________________________________ (ex. Neck, foot, scoliosis, etc.) 4. Option Exam – should be done if history is positive. Comments: Clearance:
A. Cleared B. Cleared after completing evaluation/ rehabilitation for: ________________________ C. Not cleared for : Due to: _______________________________________________________________________ Recommendation(s):_____________________________________________________________ ______________________________________________________________________________ I certify that I have examined the above student athlete and that such examination revealed (____conditions ____no conditions) that would prevent this student from participation in interscholastic sports. Are you licensed to practice medicine in the United States? ____Yes ____No Print Name _____________________________________ Signature _______________________________________ Phone Number ( )____________ Address _____________________________________________________ Date _____________ If student-athlete is not qualified, list reasons for disqualification: _________________________ (The following are considered disqualifying until medical and parental releases are obtained: acute infections, obvious growth retardation, diabetes, jaundice, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or hypertension, enlarged liver or spleen, hernia, musculoskeletal deformity associated with functional loss, history of convulsions or concussions, sickle cell trait, absence of one kidney, eye, testicle, or ovary, etc.) Insurance Notification
The purpose of this form is to inform you of the health insurance policy that went into effect at Montana State University-Northern in the Fall of 2005. Please read this entire letter carefully, sign it, and date it at the bottom. It is important that this letter be signed and dated by the Parent/Guardian/Participant of the student-athlete. You(r) son/daughter will not be eligible to participate in athletics at MSU-Northern until this document is completed and handed in. If you have any questions, please call: Christian Oberquell LAT, ATC- Head Athletic Trainer 406-265-4109 Nichole Borst LAT, ATC- Athletic Trainer 406-265-3593 Health Insurance Coverage Agreement

As the parent/legal guardian/participant of ________________________, I understand that Montana State
University-Northern does not carry health insurance for their student-athletes. Therefore, I realize that ALL
medical bills incurred as a result of my son/daughter participating in athletics at MSU-Northern are my
responsibility. I realize that it is mandatory for my son/daughter to be adequately covered by health
insurance while participating in athletics at MSU-Northern. This health insurance policy that I have chosen,
covers my son/daughter for accidents that occur from sports participation (broken bones, torn ligaments,
dislocation, etc….). If I cancel or have my medical insurance discontinued for any reason, either voluntarily
or involuntarily, I realize that all medical bills that may accumulate are still my responsibility and not the
responsibility of MSU-Northern or its employees. It is the responsibility of the Parent/Guardian/Participant
to determine if the insurance the student-athlete is currently covered under is adequate for athletic
participation and will cover the student-athlete in the state of Montana State University-Northern. Should
the insurance not cover athletics or in the state of Montana all medical bills will be the responsibility of the
parent/guardian/participant. The student-athlete must be covered during all participation of any type of
sport/team related activity throughout the school year. This includes all pre-season, in-season, postseason
and off-season activities that take place during the school year and season of the sport. If the student-athlete
is not covered during any of this time, they will not be allowed to participate. Any injury incurred will not
be the responsibility of Montana State University-Northern. It is the recommendation by the MSU-
Northern Athletic Training staff that the student-athlete be covered for all 9-10 months while at school.
I have read the above agreement and understand its contents.
Print Student-Athlete’s Name ___________________________________________
Signature of Student-Athlete ____________________________________________
Sport of Student-Athlete _______________________________________________
Print Parent/ Legal Guardian’s Name ______________________________________ *Signature of Parent/ Legal Guardian ______________________________________ Insurance Travel Form
Student-Athlete Name: ______________________ Sport (s): _______________________________ Age: _________ Local (School) Address: ____________________ City: ________________ Zip Code: _________ Home Address: __________________________ City: ________________ Zip Code: _________ Emergency Contacts:
Emergency Contact #1: Name: _____________________ Phone: ______________ Relationship: ___________ Emergency Contact #2: Name: _____________________ Phone: ______________ Relationship: ___________ Personal Information:
Allergies: ___________________________________ Medications: _________________________________ Circle if any apply: Other Conditions: _______________________________ Insurance Information:
Insurance Company: ___________________________________________ Address: _____________________________________________________ Phone Number: (____)__________________ Circle: HMO/PPO/Other: __________________ Policy Holder’s Name: _______________________________________ Policy or Member ID #: ____________________________ Permission to Share Medical Information
I, _________________________, do allow the Montana State University-Northern Athletic Training Staff to discuss my Protected Health Information with my coaching staff and others when necessary, (see below). I understand that this information may be pertinent to the decision of participating that day during practice or competition. The following is the type of information that may need to be discussed: Injuries Illnesses Rehabilitations Progress notes Past medical information that may affect participation status X-rays Test results The following are the people this information may need to be discussed with: Coaches of the sport(s) I participate in Other athletic training staff members MSU-Northern Team physicians Campus nurse Personal physician Athletic Director Professional teams – only after a waiver has been signed for that particular request Parents/Guardian and/or spouse HAAC/NAIA – in regards to eligibility status I understand that by not signing this release, I will not be denied treatment for injuries; however it may affect my participation status for the coaching staff. Should I choose to revoke the permission to share medical information I must do so in writing. This authorization will expire one academic year from the date it is signed. Student-Athlete Print Name ________________________________________________ Student-Athlete Signature__________________________________________________ Date__________ * This information will be handled in strict accordance with the Family Educational Rights and Privacy Acts of 1974 (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPPA). The student-athlete will be granted a copy of this form upon release of medical information, or upon request at any time. Permission to Provide Medical Treatment
I, _____________________________, hereby give my permission to undergo medical treatment for any injury or illness that may be sustained or acquired by me while engaged in intercollegiate athletics at Montana State University-Northern or at any College or University in which Montana State University-Northern will compete against, by Medical Personnel that is a representative at the College or University. I understand that the medical personnel will perform only those procedures that are within their training, credentials, and scope of professional practice to prevent, care for, and rehabilitate athletic injuries. In the event that more serious medical procedures are required, such as surgery, I understand that every attempt will be make to contact my parent(s)/ guardian(s) for consent (if minor). I understand that if I suffer a potentially life- threatening injury or illness, and in the event that my parent(s)/ guardian(s) can not be reached within a reasonable period of time, that I authorize any duly licensed medical practitioner to perform such procedures as may be medically necessary to alleviate the problem. I have had time to ask questions regarding this release and all of my questions have been answered to my satisfaction. Having understood the above agreement, I freely sign this Permission to Provide Medical Treatment Agreement. Student-Athlete Print Name ________________________________________________ Student-Athlete Sign Name ________________________________________________ Date ___________ Assumption of Risk/Release of Liability
All blanks must be filled in – Sign and date at the bottom!! I, ____________________, hereby acknowledge that I have voluntarily applied to participate in the college _____________________ program at Montana State University-Northern (MSU-Northern). I am aware that _____________________ can be a hazardous activity, and I am voluntarily participating in this activity with the knowledge of the dangers involved and hereby accept any and all risks of injury or even death. As lawful consideration for being permitted by MSU-Northern to participate in this activity and use its facilities, I hereby agree that I, my heirs, distributes, guardians, legal representatives, and assigns will not make claim against, sue, attach the property of, or prosecute, MSU-Northern, any of its affiliated organizations, owners, officers, employees, agents, servants, or contractors as a result of my participation in this activity. I hereby release MSU-Northern, its affiliated organizations, owners, officers, employees, agents, servants, or contractors from all of its action, claims, or demands, I, my heirs, distributes, guardians, legal representatives, or assigns now have or may hereafter have for injury or damage resulting form my participation in _____________________. I realize the possibility that I may die, become paralyzed, or suffer brain damage or other serious injuries as a result of my participation in _____________________. I realize neither the protective equipment, the safety rules, the coaching instruction, nor the sports medicine care I am provided will guarantee my safety or prevent all possible injuries. It is the intention of the undersigned to exempt and relieve MSU-Northern and associated parties from liability for personal injury, property damage, and wrongful death. Furthermore, I attest that I am physically fit and have sufficiently trained for _____________________. I do not have any medical history or conditions that may exclude me from participation in _____________________. I have carefully read this agreement and understand its contents. I am aware that this release of liability is a contrast between myself and MSU-Northern and its affiliates. I sign of my own free will. Student-Athlete Print Name ____________________________________________ Student-Athlete Sign Name ____________________________________________ Date ____________ Buckley Amendment Consent
By signing this form, you certify that you agree to disclose your educational records. You understand that this entire from and the results of any Montana State University-Northern drug test you may take are part of your educational records. These records are protected by the Family Educational Rights and Privacy Act of 1974, and they may not be disclosed without your consent. You give your consent to disclose only to authorize representatives of this institution, its athletic conference and the NAIA, the following documents. - This form - Results of MSU-Northern drug tests - Any transcripts from your high school, this institution, or any junior college or any other four-year institutions you have attended. - Pre-college test scores and appropriately related information and correspondence (ex. testing sites and dates, letters of test score certification or appeal) - Records concerning your financial aid - Any other papers or information obtained by this institution pertaining to your NAIA eligibility. You agree to disclose these records only to determine your eligibility for intercollegiate athletics, your recruitment by this institution, your eligibility for related financial aid and the Drug Free Schools Act. Student-Athlete Print Name ________________________________ Student-Athlete Sign Name ________________________________ Date ____________ Drug Testing Consent Form
By signing this form, you certify that you agree to be tested for drugs at any time, for any reason during the academic school year. You agree to allow Montana State University-Northern (MSU-Northern) to test you for the banned drugs that are listed in the MSU-Northern Banned Drug List. This means that you agree to allow MSU-Northern to test on a year round bases for the banned drugs appearing on the MSU-Northern Banned Drug List, this list is in the student-athlete handbook and at the end of this packet. Additionally, you also agree to be tested for anabolic steroids, elevated levels of HGH, diuretics, urine manipulators, and any drug masking agent. You understand that if you test positive, you will be responsible for the payment of the drug testing fee. If you test negative, the institution/team/sport will assume the cost of the fees. You understand that if you test positive, you will be notified by the head athletic trainer, as well as an immediate suspension from participation in all athletics at MSU-Northern for a minimum of two weeks will notify you. You will be required to meet with the head athletic trainer and athletic director for further counseling. You understand that if you test positive you may be drug tested on a random basis for a period of one year. You understand that the head athletic trainer will maintain copies of your drug testing results. You understand that each individual coach may have higher standards for a positive drug test, and that a positive test will result in an application of those standards. You understand that if you test positive a second time, you and your parent(s)/guardian(s) will be notified by the head athletic trainer. You will once again be responsible for the drug testing fee. In addition, the athletic director will contact the Campus Life Office and the Financial Aid Office regarding your drug test results. You understand that you will be suspended from participating in MSU-Northern athletics for a full academic year. You understand that this consent and results of your drug test, if any, will only be disclosed in accordance with the provisions of the Buckley Amendment Consent. You agree to disclose your drug testing results only for the purpose related to your eligibility, the federal government financial aid guidelines, and Drug Free Schools Act. I have read the above MSU-Northern Drug Testing Consent Form and agree to abide by the MSU-Northern Substance Abuse Policy. Student-Athlete Print Name ________________________________ Student-Athlete Sign Name ________________________________ Date ____________ BANNED DRUG LIST:
(a) Stimulants:
amiphenazole methylenedioxy methamphetamine amphetamine (MDMA, ecstasy) bemigride
methylphenidate benzphetamine nikethamide bromantan pemoline caffeine1 (guarana)
pentetrazol chlorphentermine phendimetrazine cocaine phenmetrazine cropropamide
phentermine crothetamide phenylpropanolamine (ppa) diethylpropion picrotoxine
dimethylamphetamine pipradol doxapram prolintane ephedrine (ephedra, strychnine ma huang)
synephrine (citrus aurantium, ethamivan zhi shi, bitter orange) ethylamphetamine and related
compounds.
fencamfamine The following stimulants are not meclofenoxate banned:
methamphetamine phenylephrine pseudoephedrine
(b) Anabolic Agents: anabolic steroids androstenediol methyltestosterone androstenedione
nandrolone boldenone norandrostenediol clostebol norandrostenedione
dehydrochlormethyl-norethandrolone testosterone oxandrolone
dehydroepiandro-oxymesterone sterone (DHEA) oxymetholone dihydrotestosterone stanozolol
(DHT) testosterone2dromostanolone tetrahydrogestrinone (THG) epitrenbolone trenbolone
fluoxymesterone and related compounds gestrinone mesterolone other anabolic agents
methandienone methenolone clenbuterol
(c) Substances Banned for Specific Sports:
Rifle: alcohol pindolol atenolol propranolol metoprolol timolol nadolol and related compounds
(d) Diuretics:
acetazolamidebendroflumethiazide benzthiazide bumetanide chlorothiazide chlorthalidone
ethacrynic acid flumethiazide furosemide hydrochlorothiazide hydroflumethiazide
methyclothiazidemetolazonepolythiazide quinethazone spironolactone (canrenone) triamterene
trichlormethiazide and related compounds
(e) Street Drugs:
heroin tetrahydrocannabinol marijuana3 (THC)3
(f) Peptide Hormones and Analogues: corticotrophin (ACTH) human chorionic gonadotrophin
(hCG) luteinizing hormone (LH) growth hormone(HGH, somatotrophin) insulin like growth
hormone (IGF-1)
All the respective releasing factors of the above-mentioned substances also are banned:
erythropoietin (EPO) sermorelin darbepoetin
(g) Definitions of positive depends on the following: for caffeine—if the concentration in urine
exceeds 15 micrograms/ml. 2for testosterone—if the administration of testosterone or use of any
other manipulation has the result of increasing the ratio of the total concentration of testosterone
to that of epitestosterone in the urine to greater than 6:1, unless there is evidence that this ratio is
due to a physiological or pathological condition. 3for marijuana and THC—if the concentration
in the urine of THC metabolite exceeds 15 nanograms/ml.

Source: http://www.msun.edu/athletics/sportsmed/Returning%20Medical%20Forms2012%20(2).pdf

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