UNIVERSITY OF ALBERTA Athletics
-Varsity Team:__________________________
Returning Male Medical Form
Year of Eligibility: (Entering into)
2015-2016 Athletic Season Last Name: _______________________________________ Local Address: ____________________________ Local Phone: (
First Name: ___________________________________
City: _______________________
Prov.: _____ Postal Code: ________
) ________________ E-Mail: ___________________________ Age:_______
D.O.B.: ___________________ Day
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Month
Student No.: _______________
Prov. Health Care #: ________________ Prov: ______
Year
Emergency Contact(local): __________________________
Relationship: ______________
Phone: __________________
Emergency Contact (family): ________________________
Relationship: ______________
Phone: __________________
Medications: Please list all prescribed and over-the-counter medications and supplements you are currently taking: ________________________________________________________________________________________________________________________________ Do you have allergies? Yes
No
If yes, please specify your specific allergy: ____________________________________________________________
WITHIN THE PAST YEAR… (Explain all GENERAL QUESTIONS
Yes
No
1. Has a doctor denied or restricted your participation in sports for any reason? Please explain below. 2. Have you been admitted to hospital for any reason? 3. Have you had surgery? Identify surgeries below 4. Have you been advised to be on any medication on a regular basis? Identify medications in space below 5. Have you had a skin infection? Identify below what infection and when. 6. Have you had any illness or medical conditions lasting longer than one week? 7. Have you had an injury requiring you to miss more than one practice or game? 8. Have you had an injury requiring treatment/therapy? 9. Do you currently have an incompletely healed injury? 10. Have you had a concussion, or hit to the head causing confusion, headache, or memory problems? 11. How many? When? 12. Have you had numbness, tingling or weakness in your arms or legs after a hit or a fall? 13. Have you been tested for a blood-bourne pathogen? (ie HIV, Hep B or C). Please explain test results below. 14. Have you experienced coughing/ wheezing with exercise? 15. Have you experienced frequent or severe headaches? 16. Have you got lightheaded, dizzy or felt more short of breath than expected during exercise? 17. Have you experienced heat exhaustion or heat stroke? 18. Has a doctor ordered testing for your heart? (including ECG, EKG, ultrasound, etc.)
GENERAL QUESTIONS
Yes
No
19. Have you experienced heart palpitations (when you heart feels as if it is pounding/racing) 20. Have you experience unexplained weight loss/gain? 21. Do you use any special equipment? (ie brace, pads, orthotics, etc)
22. Is there anything else you wish to discuss with the U of A medical staff? “YES” answers in the space provided)
Explain ‘YES’ answers
_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________
Your medical information will be collected and stored in a confidential manner at the University of Alberta. Information pertaining to your ability to participate in the varsity athletics program will be shared only with those in the school administration who need to know. By signing this form, you are giving us permission to share medical information from the U of A and information that may arise during the upcoming season and will expire at the conclusion of your involvement and particiaption in the varsity athletics program. This consent to disclose your specific medical information relating to your ability to participate in competition and practice will include any and all members of the sports medicine team (your personal physician, team physicians, athletic therapists, physiotherapists, varsity therapists, and if appropriate, coaches and/or U of A administration). Specific medical information will not be discussed with non-healthcare professionals, but final clearance or disqualification decisions may be reviewed with school officials. Consent to Disclose: Yes No
Athlete Signature: ______________________ Date: R:\Medical Forms\Male Athlete Form 2013-14 Partially derived from the 2010 Pre-participation Physical Evaluation History and Physical Examination form, by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement. The original document can be found at http://ppesportsevaluation.org/evalform.pdf. ** The information contained on this medical form may be used by University of Alberta Varsity Team Physicians, Team Therapists, and Student Trainers in order to provide appropriate medical care. These records will be managed in accordance with the Health Information Act
VARSITY HEALTH REGISTRATION FORM Personal Contact Information Name: _______________________________________ PHN: ___ ___ ___ ___ ___ - ___ ___ ___ ___ (____) Surname Given Name Middle Personal Health Number Province Address: _________________________________________ City: _______________________ Prov: ______ Postal Code: _______________ email address: _________________________________________________ Phone: cell (
) ______ - ________
home (
) ______ - ________
Date of Birth: _______ /______ /____ Year Mon Day
Age: ____
Gender:
-Varsity Team: _________________________
Eligibility Year (circle):
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YOU MUST COMPLETE THE FOLLOWING SUPPLEMENTAL HEALTH/DENTAL INSURANCE INFORMATION:
I do not have private insurance Insurance Company:_______________________________________________________________________ Plan/ID/Employee/Group #s:_______________________________________________________________ Plan Holder: ______________________________________________________________________________ Name Relation Does your plan cover any of the following (please circle):
Physiotherapy
Massage
Athletic Therapy
Amount($) or % covered per therapy visit:____________ Total ($) Coverage for Dental:_____________ Total policy Coverage For Physiotherapy: ____________ Total $ Coverage for Equipment: ___________ Emergency Contact Information Emergency Contact ________________________________________________Phone: (___)____-________ Name Relation Family Physician: _________________________________________________Phone: (___)____-________ Patient Advisement of Purpose of Collection of Health Information Please be advised the registration information collected will be used for creating a patient file and billing purposes. The information is being collected under the authority of sections 20(b) and 21(1) the Health Information Act. The Health Information Act provides for sharing of patient information between Varsity Health Providers when said sharing contributes to the continuing care and treatment of the patient. If you have any questions about the collection and use of your personal/health information, please contact the Glen Sather Sport Medicine Clinic at 780-407-5160. Your signature below indicates you understand and comply with the above statements. Missed appointments and short notice cancellations result in inefficient use of Healthcare Provider resources. In an effort to decrease the incidence of these occurrences, a $25.00 fee for any missed appointments with a Physician or Varsity Therapist will be levied.
Patient Signature:_______________________Print Name:________________________ Date: ___________ If under 18 years of age, must be signed by parent/guardian
Glen Sather Sports Medicine Clinic Phone: 780-407-5160 Fax: 780-407-5667 Edmonton Clinic Level 2 11400 University Avenue , University of Alberta, Edmonton, Alberta T6G 1Z1 R:\Medical Forms\Male Athlete Form 2013-14 Partially derived from the 2010 Pre-participation Physical Evaluation History and Physical Examination form, by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement. The original document can be found at http://ppesportsevaluation.org/evalform.pdf. ** The information contained on this medical form may be used by University of Alberta Varsity Team Physicians, Team Therapists, and Student Trainers in order to provide appropriate medical care. These records will be managed in accordance with the Health Information Act
