Florida A&M University Athletic Pre-Participation History

The National Collegiate Athletic Associations policies recommend that all student-athletes have a qualifying medical evaluation upon initial entrance into an institutions athletic program, and an annual health status review. Florida A&M University supports this NCAA policy. Further medical evaluations may be required for specific matters. Name: FAMU ID #: 1
st

Date: Sport: 2 3rd

Gender (M/F): Age: DOB: Year of Athletic Participation at Florida A&M University:

4th

5th

I consent to proceed with this athletic physical exam or screening. I certify that all information I give during the course of this examination is true and correct. I understand that passing the physical examination does not necessarily mean that an athlete is qualified to engage in athletics, but only that the medical evaluation did not find a medical reason to disqualify the athlete at the time of said examination. My signature affirms that I have read and understand the material above and have been given an opportunity to ask questions. ______________________________________________________
Athletes Signature
Mark Yes or No and circle the questions you dont know the answer to: . Yes No

Date
Yes No

1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Have you ever been diagnosed or treated for high blood pressure or diabetes? 3. Have you ever been told you have an irregular heart beat, heart murmur or other heart condition? 4. Do you or any family member have Marfans Syndrome? 5. Has any family member died before the age of 50? 6. Have you ever been diagnosed with asthma, other respiratory ailment or allergies? 7. Do you cough, wheeze or have difficulty breathing during or after exercise? 8. Are you allergic to any medications, insect stings or insect bites? 9. Have you ever been diagnosed with anemia or having an iron deficiency? 10. Have you been diagnosed with hepatitis in the last 3 years? 11. Have you been treated for any infectious virus in the last year? 12. Have you ever felt faint or passes out with exercise or in the heat? 13. Have you ever been knocked out or had a concussion within the past 3 years? 14. Have you ever had any type of seizure or informed that you may have epilepsy?

15. Have you had an illness or injury in the past year that required overnight hospitalization? 16. Have you had any illness or injury that required surgery? 17. Have you ever had any broken or fractured bones or dislocated joints? If yes, circle below. 18. Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast or crutches? If yes, circle below.
Head Upper back Neck Lower back Shoulder Hip Upper Arm Thigh Elbow Knee ForeArm Calf/ Shin Hand/ Fingers Ankle Chest Foot/ toes

19. Do you wear glasses or contact lenses when playing your sport? 20. Do you wear protective eye wear, such as goggles or a face shield? 21. Do you wear dental appliances or wear a hearing aid? 22. Are you taking any prescribed or over-the-counter medication on a regular or continuous basis? 23. Are you, your parents or grandparents of African American, African, Hispanic, Arab, Greek, Italian or East Indian descent? 24. Have you ever been told you have sickle cell disease or trait? FEMALES ONLY 25. Do you have or have you had any menstrual irregularities? 26. Date of last menstrual period ____________________

Explain Yes answers here (use additional page if necessary):_________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
05/08 TT

Florida A&M University Athletic Physical

Athletic Physical Examination

Name: _______________________________ ID # _________________________________ Incoming: _________ Returning: _________

Height: ____________________ Weight: ______________ Pulse: ______________ BP: ________________ Vision: w/correction: R ___________ L ____________ w/o correction R ___________ L __________
NORMAL MEDICAL ABNORMAL

Skin Head Eyes Ears Nose Throat & Mouth Teeth Neck Lungs & Chest Heart Abdomen Hernia (male athletes) OB/GYN discussion
MUSCULOSKETAL

Neck Back/Spine Shoulders/arms Elbows/forearms Hips Quadriceps/Hamstrings Knees/Legs Ankles Feet/toes

Sickle cell screen Other: This athlete is cleared to participate in sport with no restrictions. This athlete is cleared to participate in sport with the following specifications: ________________________ This athlete may not participate in sport for the following reasons:_________________________________ ________________________________________________________________________________________ Provider Signature:___________________________________________________ Date:_________________ ___________________________________________________________________________________________
Physician Signature Date
Office Stamp (Address/Phone/Fax # mandatory)

05/08 TT

PARENTS INSURANCE FORM

E/03

Our athletic accident policy, which provides insurance for your son or daughter for injuries occurring while participating in the play or practice of intercollegiate sports, is EXCESS or SECONDARY to any other collectible group insurance benefits. This means that any claim for benefits must first be field with the group insurance company providing coverage to your son or daughter through your employer or your spouses employer. After they have paid all available benefits, our athletic insurance company will consider remaining amounts based on USUAL and CUSTOMARY charges. WE, AS THE SCHOOL, DO NOT HAVE THE OPTION OF WAIVING THE REQUIREMENT OF FILING WITH YOUR GROUP INSURANCE .

PLEASE NOTE; 1. Most employers group insurance allows dependent coverage to be continued to age 25, if the dependent is a full-time student. Do NOT drop dependent coverage while your son or daughter is participating in intercollegiate athletics. 2. Claims against your group insurance plan DO NOT increase your individual insurance premiums. THE FOLLOWING INFORMATION AND AUTHORIZATION MUST BE FULLY COMPLETED, SIGNED AND RETURNED; please circle the individual listed as the insured on your primary/personal plan and complete all requested information. Father/Guardian/Spouse/Self (circle one) Name Social Security # Home Address (Street) (City, State & Zip Code) Employers Name Employers Address______________________________________________________________________________________ (Street) (City, State & Zip Code) Home Telephone # Work Telephone # Name of Group Insurance Company Group #____________ Policy # _________________________ Mailing Address for Claims Telephone # (Street) (City, State & Zip Code) IS YOUR DEPENDENT SON/DAUGHTER COVERED UNDER THE ABOVE POLICY? YES ________ NO _______ Does your insurance require: A second opinion for surgery? YES ___ NO ___Is your primary insurance an HMO? YES ____ NO ____ Pre-authorization for services? YES ___NO ____Is your primary insurance a PPO? YES ____ NO ____ Mother/Guardian/Spouse/Self (circle one) Name Social Security __________________________________ Home Address (Street) (City, State & Zip Code) Employers Name EmployersAddress________________________________________________________________________________________ (Street) (City, State & Zip Code) Home Telephone # Work Telephone # Name of Group Insurance Company Group # Policy # ________________________ Mailing Address for Claims Telephone # _____________________ (Street) (City, State & Zip Code) IS YOUR DEPENDENT SON/DAUGHTER COVERED UNDER THE ABOVE POLICY? YES _____ NO _______ Does your insurance require: A second opinion for surgery? YES ___ NO __Is your primary insurance an HMO? YES ____ NO ____ Pre-authorization for services? YES ___NO ___Is your primary insurance a PPO? YES ____ NO ____
I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained by .

My son/daughter is NOT covered under my group insurance. I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. A photostatic copy of the authorization shall be considered as effective and valid as the original.

Date

Signature of Parent

05/08 TT