In addition to the completion of the physical exam and immunization** record that must be completed by all students, each of the following documents and tasks must be completed and returned to the Lasell College Athletic Training Office by all first year student-athletes before participation is permitted. Athletic Health History Questionnaire Emergency Medical Information/Demographic Form Authorization for Disclosure of Protected Health Information Medical Consent, Sports Safety and Medical Statements Insurance Statement Front and Back Copy of Insurance Card All documents completed, dated, and signed by athlete (and parent/guardian if under 18 years of age) _______ Either the Sickle Cell Waiver Form or the Sickle Cell Disclosure Form **All first year student-athletes must have a physical exam within 6 months of initial participation. Please mail or fax all completed documents to: Lasell College Athletic Training Office 1844 Commonwealth Ave. Newton, MA 02466 Fax: 617-243-2037 To Be Completed by Certified Athletic Trainer Clearance for participation in athletics with no limitations. __________ Clearance pending further evaluation or testing. (Please explain) Referral to other health care professional prior to clearance. (Please explain) Clearance with limitations. (Please explain) Disqualification from participation in athletics at this time. (Please explain) Signature of Certified Athletic Trainer Date Sport(s): Lasell College Athletic Health History Questionnaire This form will be kept confidential & will be used as supplementary information by the examining physicians, nurse practitioners, physicians assistants, nurses and certified athletic trainers. Name: Height: Student ID#: Weight: Social Security #: Resting Blood Pressure: Date of Birth: Resting Heart Rate: Current Age: Vision: R: L: Glasses/Contacts (circle) Expected Year of Graduation: Urinalysis: Blood: Protein: To be completed by Athletic Training Staff **Please fill-in and answer all questions as completely as possible, including dates and side (Right/Left) involved. ** Family History Have any of your blood relatives had any of the following conditions? Yes No Sudden Death (Before Age 55) Relation: Yes No Diabetes Relation: Yes No Seizures Relation: Yes No Heart Disease Relation: Yes No Blood Disease (Leukemia, Sickle Cell, etc.) Relation: Yes No High Blood Pressure Relation: Yes No Marfan Syndrome Relation: Yes No Alcohol or Drug Dependency Relation: Personal Medical History I. General 1. Have you ever been diagnosed or treated for either of the following conditions? Yes No a. Attention Deficit Disorder (ADD) Yes No b. Atte nti on Deficit Hyperactivity Di sord er (ADHD) If yes, are you curr entl y taking pr esc ribed medicati on for this conditio n? Name of Medic ati on(s): *Due to new NCAA regulations please be prepared to provide us with appropriate documentation * 2. Have you ever had any of the following medical conditions? Yes No a. Thyroid Disease Date: Yes No b. S kin Disease Dat e: Yes No c. Blood in Urine Dat e: Yes No d. U rinary In fection Dat e: Yes No e. M us cular Di sease Dat e: Yes No f. Birth Defects Dat e: Yes No g. Travel Sic kn ess Dat e: Yes No H. Skin Infections Dat e: 3. Have you been treated for any of the following during the past year? Yes No a. infectious mononucleosis (“mono”) Date: Yes No b. viral pn eumon ia Dat e: Yes No c. tub erc ulosis Dat e: Yes No d. other infecti ous diseases including: hepa titi s, me asles, m umps, etc. Date: Yes No 4. Have you ever been treated for Rheumatic fever? Date: Yes No 5. Have you ever been diagnosed or treated for high blood pressure (hypertension)? If yes, are you currently taking prescribed medication for this condition? Name of Medication(s):_ Yes No 6. Have you ever been diagnosed or treated for circulatory problems? 7. Have you ever been diagnosed with any of the following? Yes No a. Abno rmal bruising or blee ding Yes No b. Blood disease Yes No c. Blood clotting disorders Yes No d. Anemia Yes No e. Sickle Cell Trait or Sickle Cell Anemia Yes No 8. Have you ever suffered a seizure or been diagnosed with epilepsy? If yes, are you currently taking prescribed medication for this condition? Name of Medication(s): 9. Have you ever suffered from or been treated for any of the following? Yes No a. Amnesia Yes No c. Em oti ona l Di sorder Yes No d. Eati ng Di sorder Yes No e. Dru g/ Alc oho l Abu se Yes No f. Steroid Use Yes No 10. Have you ever been diagnosed with diabetes? If yes, how is this condition being treated? Medication, exercise, diet? Yes No 11. Have you had a tetanus shot in the past 5 years? Date: Yes No 12 . Are you miss ing any paired orga ns (eye, kid ney, ova ry, and testicle )? Yes No 13 . Have you ever been trea ted fo r a herni a? Dat e: Treat ment: Yes No 14 . Have you had your append ix remov ed? Yes No 15 . Are you al ler gic to any medic at ions? List: Yes No 16 . Do yo u hav e any ot her aller gies? (foo d, in sect , en vir onmen ta l) Yes No 17 . Have you had any recent (within the past 2 years) sur gery ? Yes No 18 . Do yo u suff er from any menstru al cy cle irr eg ulari ties (amen orrhe a, dysmen orrhea)? Yes No 19 . Ha s yo ur wei ght fluctu ated 20 pounds or more duri ng the past year? II. Cardio-Respiratory 20. Have you ever been diagnosed with any of the following? Yes No a. Heart Murmur Yes No b. An enlarged heart (hypert roph ic cardiomyopa thy) Yes No c. An irr egu lar heartbeat (arr hyt hmi a) Yes No d. Marfan synd rome Yes No e. Any other heart rel ated conditio ns Yes No 21. Do you ever experience chest pain or discomfort during exercise? Yes No 22 . Do yo u experience epi sodes of ne ar-fa inting during exercise? Yes No 23 . Do yo u ever experience excessive unexplain ed shortness of bre at h or fat igue during exercise? Yes No 24 . Have you ever been trea ted fo r asthma? If yes, are you currently on prescribed medication for asthma? Name of Medication(s): III. Head and Neck 25. Have you been knocked unconscious or suffered a concussion during the past: Yes No a. 1 year? If yes, how many times? _______ Yes No b. 3 years? If yes, how many times? Yes No c. If yes, were you treated by a physician or other health care professional? 26. Have you experienced any other mild head injuries (“gotten your bell rung”) that required you to seek medical attention during the past: Yes No a. 1 year? If yes, how many times? Yes No b. 3 years? If yes, how many times? Yes No 27. Have you ever suffered or been treated for amnesia? ________________________________________ Yes No 28. Do you suffer from migraine or cluster headaches? If yes, do you take medication for them? Yes No 29. Have you ever suffered a whiplash type injury to your neck that required you to seek medical care? Yes No 30. Do you have a history of brachial plexus injuries (burners or stingers)? Yes No 31. If you answered yes to # 28, have you been required to wear a neck protective device such as a neck roll or collar for collision sports (football, lacrosse)? Yes No 32. Have you ever suffered a fracture (broken bone) to any of the vertebrae in your neck? IV. Vision, Hearing, Dental, Facial Yes No 33. Do you have vision in both eyes? If no, give details: Yes No 34 . Do yo u wear glass es or cont act len ses? Ple ase Cir cle Yes No 35 . Do yo u wear glass es or cont act len ses whi le particip ating in sports? Ple ase Cir cle Yes No 36 . Do yo u hav e he aring in bot h ears? Yes No 37 . Do yo u hav e any conditi on that requires yo u to wear a he aring aid? Yes No 38 . Do yo u curr ently wear any dent al appli ances (br aces, pe rmanent bridge )? Yes No 39 . Have you ever been trea ted fo r TMJ syndrome, a c onditi on aff ect ing the jaw? Yes No 40 . Have you ever br oken yo ur nose? Dat e: V. Shoulder and Arm 41. Do you have a history of any of the following shoulder injuries? Yes No a. shoulder dislocation Right Left Date: Yes No b. su bluxati on (p artial dislocation) Righ t Left Dat e: Yes No c. “separate d” sh oulder Righ t Left Dat e: Yes No d. ro tat or cuff muscle strain Righ t Left Dat e: Yes No e. impingement syn dr ome Righ t Left Dat e: Yes No f. other mus cular stra in Righ t Left Dat e: Yes No g. bice ps te ndo nit is Righ t Left Dat e: Yes No h. bursit is Righ t Left Dat e: Yes No i. Thor acic outlet syn dr ome Righ t Left Dat e: Yes No 42. Have you ever had surgery to correct a shoulder injury? Date: Yes No 43 . Have you ever fractured (br oken) yo ur arm? Righ t Left Dat e: Yes No 44 . Have you ever fractured your cl av icle? Righ t Left Dat e: VI. Elbow and Forearm 45. Do you have a history of any of the following elbow or forearm injuries? Yes No a.