university of south alabama sports medicine 6001 usa … · 6001 usa drive south, suite 35 mobile,...

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UNIVERSITY OF SOUTH ALABAMA SPORTS MEDICINE 6001 USA Drive South, Suite 35 Mobile, AL 36688

HPELS 251-460-6874 / 251-460-7607 (Fax) Football 251-445-9551/ 251 445-9568 (Fax)

On behalf of the Sports Medicine Staff and the Department of Athletics for the University of South Alabama,

we would like to welcome you to the Jaguar family. Our mission is to provide quality medical care for the

intercollegiate student-athletes of our university. Prevention, recognition, and treatment of athletic injuries and

illnesses by the Sports Medicine Staff will enhance excellence within university athletic programs and

contribute to the total development of the student-athlete.

Please read through the packet carefully, and complete all forms thoroughly, including the necessary signatures

in the area designated. If you are under 19, please have a parent or guardian sign each form as well.

Every student-athlete competing for the university must have a physical prior to any workouts or competition.

A complete medical history is an essential part of that process. Please print, review, and complete the following

forms and bring them with you to your physical. Failure to have these forms completed at the time of the

physical will cause delays to the start of your participation with your team.

Please bring with you any physician notes from previous operations, significant injuries, including if available,

MRI’s, and CT scans.

It is a requirement of participation in intercollegiate athletics that you complete a pre-participation physical

exam to include medical clearance, sign all medical documents, complete sickle cell requirements, and provide

valid medical health insurance. We look forward to helping you achieve your goals and progress in your

intercollegiate academic and athletic career as a South Alabama Jaguar. Please feel free to contact me or my

staff at (251) 445-9551 or [email protected].

Sincerely, Jinni Frisbey, MEd, ATC Associate Athletic Director for Sports Medicine / Senior Woman Administrator / Title IX Coordinator

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UNIVERSITY OF SOUTH ALABAMA DEPARTMENT OF ATHLETICS MEDICAL HISTORY QUESTIONNAIRE

Please answer all of the following questions in detail. Incomplete forms may be returned to you resulting in a delay in your physical process. This process must be complete before you will be allowed to participate. NAME:___________________________________ Sex:______ DATE OF BIRTH_____/______/_______

Last First Middle mm dd yyyy

SSN: ___________-___________-____________ JAGUAR ID#:_______________________ SPORT(S):____________________________________________________________________________ (At USA)

LOCAL ADDRESS: ________________________________________________________________ __ (AT USA) ________________________________________________________________________ __ City State Zip LOCAL PHONE: ( )__________________________CELL PHONE: ( )_______________________ EMAIL ADDRESS:_____________________________________________________________________ PARENTS’ NAMES:____________________________________________________________________ __ Mother Father PARENTS’ HOME PHONE: ( ) ( )______________________________ PARENTS’ CELL PHONE: ( ) ( )______________________________ PARENTS’ WORK PHONE: ( ) ( )______________________________ EMAIL ADDRESS: __________________________________________________________________ ___ HOME ADDRESS: ________________________________________________________________________ (Permanent) _____________________________________________________________________ __ City State Zip IN CASE OF EMERGENCY, PLEASE CONTACT: (other than parent/guardian) NAME: ____________________________________RELATIONSHIP: __________________________ __

HOME PHONE :( )_________________________WORK PHONE: ( )_______________________ __ CELL PHONE :( )_________________________EMAIL: ___________________________________ __

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Name ________________________________ Jaguar ID ____________________ D.O.B __________________

The 12 Element AHA Recommendations for Pre-participation Cardiovascular Screening of Competitive Athletes

Student- Athlete please answer Yes or No to the following 8 questions: Medical history about YOURSELF and Family History:

Personal history – Have you ever experienced:

Yes - No 1. Exertional chest pain/discomfort

Yes - No 2. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise

Yes - No 3. Unexplained syncope/near-syncope

Yes - No 4. Elevated systemic blood pressure

Yes - No 5a. Prior recognition of a heart murmur Yes - No 5b.Heart surgery or diagnosed conditions of the heart

Family history – Do any family member have or have experienced

Yes - No 6. Premature death (sudden, unexpected, or otherwise) before age 50 years due to HEART DISEASE, in 1 relative

Yes - No 7. Disability from HEART DISEASE in a close relative <50 years of age

Yes - No 8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias

Physical examination FOR DOCTORS ONLY!

Yes - No 9. Heart murmur

Yes - No 10. Abnormal femoral pulses to exclude aortic coarctation

Yes - No 11. Physical stigmata of Marfan syndrome

Yes - No 12. Abnormal brachial artery blood pressure (sitting position) BP/Left Arm ________________ BP/ Right Arm _______________

*Parental verification is recommended for high school and middle school athletes.

Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.

Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.

Preferably taken in both arms.37

Physician recommendation for cardiac follow up YES or NO Evaluation Notes:_________________________________________ Evaluated By:

Physician Name Physician signature Date of Evaluation

4GENERAL MEDICAL

Please circle any of the following that you currently have; have had, and/or are currently being treated for:

Anemia Heat Illness (Cramps, Exhaustion, Etc.) Migraines

Appendicitis Hemophilia Mononucleosis

Bladder Illness/Injury Hepatitis Mumps

Bleeding Tendencies Hernia Palpitations

Chicken Pox Hiatal Hernia Pleurisy

Diabetes High/Low Blood Pressure Pneumonia

Drug/Alcohol Dependency HIV/AIDS Polio

Emotional Disturbance (Depression) Kidney Disease/Injury Spleen Injury

Epilepsy Leukemia Stomach Trouble

Freq. or Severe Headaches Liver Disease/Injury Sickle Cell Trait

Fibromyalgia Lupus Tuberculosis

Hearing Defect Measles Thyroid Disorder

Heart Disease/Heart Surgery Menstrual Disorder Ulcers

Please explain ANY of the circled responses:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

GENERAL MEDICAL – PLEASE COMPLETE THE FOLLOWING QUESTIONS:

YES NO Have you ever lost a paired organ (i.e.: kidney, eye, testicle, etc...?

YES NO Have you ever been told that you should wear a brace, be taped, etc.?

YES NO Have you ever been told to have a test or surgery that you did not elect to do?

YES NO Have you ever been in a car accident that you were injured?

YES NO Have you ever been denied participation in a sport?

YES NO Do you have any other medical problems not mentioned above?

YES NO Have you ever passed out while exercising?

YES NO Have you ever passed out for any reason?

YES NO Do you frequently cough after exercising?

YES NO Have you ever had chest pain while exercising?

YES NO Have you ever been diagnosed with a heart condition, rhythm defect, or suffered a heart attack?

YES NO Have you ever seen a cardiologist, pulmonologist, or neurologist?

YES NO Has anyone in your family died before the age of 50?

YES NO Are there any diseases that run in your family (diabetes, heart disease, etc...)?

YES NO Have you ever been told or you have suspected you have an eating disorder?

YES NO Do you have any screws, pins, pacemaker, or other implants?

YES NO Are you currently taking any medications regularly?

YES NO Have you been told to take a medication that you no longer take?

YES NO Are you now or have you ever used an anabolic steroid or growth hormone?

YES NO Have you ever suffered an injury to your genital/groin area?

Please explain any YES answers:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

_________________________________________________________________________________________________

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VISION AND DENTAL

YES NO Do you wear dentures, partials, retainers, etc.?

YES NO Do you have full use of both eyes?

YES NO Do you wear contacts or glasses?

ALLERGIES

YES NO Are you allergic to any medications that you are aware of? Please circle all that apply: Aspirin,

Codeine, Cortisone, Sulfa, Anti-Inflammatory Medications, or Penicillin.

Other Medication Not Listed: _________________________________________________________________________

YES NO Hay Fever?

YES NO Insect Bites or Stings? If yes, what kind of insect(s)? __________________________________________

YES NO Any particular food? Explain: ____________________________________________________________

YES NO Other Allergies? Explain: ________________________________________________________________

HEAD

YES NO Have you ever been knocked unconscious?

YES NO Did you see a physician?

YES NO Were X-rays, CT scan, Bone Scan or MRI done? Circle any that apply

YES NO Were you admitted to a hospital or infirmary?

YES NO Did you miss any practice or game time due to a head injury or pain?

YES NO Have you ever had a concussion without losing consciousness?

YES NO Have you ever had a seizure (either convulsive or non-convulsive)?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

NECK

YES NO Have you ever had a neck injury or neck pain?



YES NO Was surgery performed?

YES NO Were you admitted to a hospital or infirmary?

YES NO Did you miss any practice or game time due to a neck injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

BACK

YES NO Have you ever injured your back or suffered from back pain?




YES NO Did you miss any practice or game time due to a back injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

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SHOULDER

YES NO Have you ever had a shoulder injury? R___ L___




YES NO Did you miss any practice or game time due to shoulder injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

ARM/ELBOW

YES NO Have you ever injured either one of your elbows? R___L___



YES NO Were you put into a cast or immobilized?


YES NO Did you miss any practice or game time due to an arm/elbow injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

WRIST/HAND/FINGERS

YES NO Have you ever injured either one of your wrists/hands/fingers? R___L___





YES NO Did you miss any practice or game time due to wrist/hand/fingers injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

HIP/THIGH

YES NO Have you ever injured either of your hips? R___ L___





YES NO Did you miss any practice or game time due to hip injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

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KNEE

YES NO Have you ever injured either of your knees? R___ L___





YES NO Did you miss any practice or game time due to knee injury or pain?


__________________________________________________________________________________________________

__________________________________________________________________________________________________

LOWER LEG/ANKLE

YES NO Have you ever injured your ankle(s)? R___ L___





YES NO Did you miss any practice or game time due to lower leg/ankle injury or pain?

Please explain any of the YES answers:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

FEET

YES NO Have you ever injured either foot? R___ L___




YES NO Did you miss any practice or game time due to foot injury or pain?

YES NO Have you ever been told that you have flat feet or high arches?

YES NO Have you ever used, or been advised to use orthotics?

Please explain any of the YES answers:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

List and describe ANY OTHER injuries you have sustained, giving dates for all and explaining their occurrence and any

current medical problems that you would like to speak with the physicians about:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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WOMEN ONLY – Female Student-Athletes complete the following:

YES NO Do you suffer from irregular menstrual periods?

YES NO Do you suffer from severe menstrual cramps?

YES NO Are you currently taking any medications for birth control and/or severe cramps?

If yes, what, how much and how often? ________________________________________________

YES NO Do you have frequent urinary tract infections?

YES NO Have you had any past pregnancies or births?

YES NO Have you ever been treated for anemia (low iron)?

YES NO Have you ever been treated for an eating disorder?

IT IS THE POLICY OF THE UNIVERSITY OF SOUTH ALABAMA DEPARTMENT OF ATHLETICS THAT

STUDENT ATHLETES WHO HAVE A MEDICALLY DIAGNOSED PREGNANCY NOT PARTICIPATE IN

ANY UNIVERSITY ATHLETIC DEPARTMENT SPONSORED COMPETITION, PRACTICE, OR

CONDITIONING ACTIVITY IF PARTICIPATION WOULD PRESENT AN UNREASONABLE DANGER TO

EITHER THE FETUS OR THE MOTHER. IN THE EVENT OF A PREGNANCY; THE UNIVERSITY, ITS

TEAM PHYSICIANS OR DESIGNATED PHYSICIANS MAY RESERVE THE RIGHT TO HOLD A STUDENT

ATHLETE OUT OF PARTICIPATION FOR SUCH REASONS.

STUDENT ATHLETE, _______________________________, AND PARENT OR GUARDIAN HAVE READ,

UNDERSTAND AND AGREE TO THE AFOREMENTIONED POLICY ON THE PARTICIPATION OF THE

STUDENT ATHLETE. STUDENT ATHLETE AND PARENT OR GUARDIAN AGREE THAT IT IS THE

STUDENT ATHLETE’S RESPONSIBILITY TO NOTIFY THE UNIVERSITY’S MEDICAL PERSONNEL OF

ANY CHANGE IN MENSTRUAL PERIODS AND/OR REPRODUCTION STATUS. STUDENT ATHLETE

AND PARENT OR GUARDIAN UNDERSTAND THAT THE UNIVERSITY DEPARTMENT OF ATHLETICS

MAY NOT BE HELD FINANCIALLY RESPONSIBLE FOR ANY PREGNANCY TESTS OR OTHER

MEDICAL PROCEDURE THE STUDENT ATHLETE MAY UNDERGO DUE TO CHANGES IN THE

STUDENT ATHLETE’S REPRODUCTIVE SYSTEM.

DATE: _________________ SIGNATURE: __________________________________________

PARENT OR GUARDIAN’S SSN: __________________________________________________

SIGNATURE REQUIRED IF PARENT/GUARDIAN: ___________________________________

UNDER 19 YEARS OF AGE

9University of South Alabama Sports Medicine

Authorization to Release Protected Health Information

I authorize and grant permission to the University of South Alabama Athletics team physicians, athletic trainers,

consultants, and/or their medical assistants to release and share protected health information concerning any injury or

illness relative to my participation in intercollegiate athletics. I authorize to release health information to coaches,

administrators, media relations, my parents/guardians, various media outlets, academic counseling staff, professors,

researchers (approved by USA Athletics), and/or the NCAA for educational purposes related to my past, present, or

future participation in athletics at the University of South Alabama.

I also authorize any medical institutions which might render medical treatment to me during this period, or may have

rendered medical care to me previously, to release all records to the University of South Alabama Team Physician or

the Assistant Athletic Director for Sports Medicine, in order that they will be better informed of my medical

condition and capabilities, while I participate in intercollegiate athletic competition for the University of South

Alabama.

NOTICE: The University of South Alabama Athletic Department and many other individuals and organizations such

as physicians, hospitals, and health insurance plans are required by law to keep your health information confidential.

If you have authorized the disclosure of your health insurance information to someone who is not legally required to

keep it confidential, it may no longer be protected by state or federal confidentiality laws.

Medical Consent

I authorize and grant permission to the University of South Alabama Athletics team physicians, athletic trainers,

consultants, and/or their medical assistants to render to the student athlete any treatment, medical or surgical care

(including drug testing) that they deem reasonably necessary to the health and well-being of the student athlete.

The student athlete and parent or guardian also hereby authorize the athletic trainers at the University of South

Alabama, who are under the direction and guidance of the University of South Alabama team physicians, to render

any preventive, first aid, rehabilitation or emergency treatment that they deem reasonably necessary to the health and

well-being of the aforementioned student athlete. Also, when necessary for executing such case, the student athlete

and parent or guardian grants permission for hospitalization at an accredited hospital.

Student Athlete Name: ________________________________________________ Sport: ______________________

Date of Birth ________/_________/_________ JAG # ______________________ Student Signature: ____________________________________________________ DATE _______/_______/_______ Parent or Guardian Signature ____________________________________________ DATE _______ /_______/______ (Required if student athlete is under 19 years of age)

University of South Alabama Sports Medicine

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Athletic Risk Warning Statement

I understand that there are inherent dangers and potential for injury related to participation in intercollegiate athletics while at the

University of South Alabama. I am also aware that intercollegiate athletic participation, even when all reasonable precautions are

taken, carries a risk of serious injury or illness – including, but not limited to, paralysis and death-due to the nature of sport. I also

understand that the risks of participation in intercollegiate athletics may result not only in serious injury or illness but also in

impairment of my future ability to earn a living and/or my quality of life.

Shared Responsibility for Sports Safety:

The rules of play, safety guidelines, equipment standards, and training are designed to protect athletes from injury, but cannot

guarantee that I will not be injured. I acknowledge that I have a responsibility to wear the required equipment and clothing, obey the

rules of my sport, utilize proper techniques, follow proper coaching techniques, and follow athletic trainers’ instructions. The student -

athlete and parent or guardian understands that equipment must be worn properly, understands that notification must be made to the

USA Equipment Specialist, Athletic Trainers, or Coaches of any defects or changes of fit in my athletic equipment. Furthermore, I

will avoid activities for which I have not trained or for which I do not feel I am qualified to perform.

FOOTBALL ONLY – Additional Information

Keep your head up, do not use your helmet to butt or spear an opposing player. This is a violation of all football rules and such

use can result in severe head injury, paralysis, or death to you, as well as inflicting possible injury to your opponent. Contact in

football may result in concussion/brain injury or neck injury. NO helmet can protect you from serious brain and/or neck injuries

that may be sustained while participating in football.

I have read and understand the significance of the above statements. I voluntarily accept risks of participation in intercollegiate sports.

I also acknowledge that I have a shared responsibility for injury prevention. In consideration of the student athlete’s being permitted to

participate in the USA Intercollegiate Athletic Program, the student athlete and parent or guardian hereby release USA, its Trustees,

officers, employees, and agents, together with all persons assisting with any phase of the program, from all liability and responsibility

for any loss or injury related to the student athlete’s participation in the USA athletic program. The student athlete and parent or

guardian further agree to indemnify and hold harmless said parties, guardians, heirs, executors, representatives or assigns.


Date of Birth ________/_________/_________ JAG # ______________________ Student Signature: ____________________________________________________ DATE _______/_______/_______ Parent or Guardian Signature ____________________________________________ DATE _______/_______/______ (Required if student athlete is under 19 years of age)


Certification of Authenticity of Answers

A. I CERTIFY THAT THE ANSWERS TO THESE QUESTIONS ARE CORRECT AND TRUE. B. I UNDERSTAND THAT AS THE STUDENT ATHLETE, I MUST REFRAIN FROM PRACTICE OR PLAY

DURING MEDICAL TREATMENT UNTIL I AM DISCHARGED FROM TREATMENT OR I AM GIVEN WRITTEN PERMISSION BY THE ATTENDING PHYSICIAN TO RESUME PARTICIPATION.

C. I UNDERSTAND THAT I MUST COMPLETE AND PASS THE PRE-PARTICIPATION PHYSICAL EXAMINATION.THIS DOES NOT NECESSARILY MEAN THAT I AM PHYSICALLY QUALIFIED TO ENGAGE IN ATHLETICS, BUT ONLY THAT THE EXAMINER DID NOT FIND A MEDICAL REASON TO DISQUALIFY ME. D. I FULLY REALIZE THAT THE UNIVERSITY OF SOUTH ALABAMA AND THE DEPARTMENT OF ATHLETICS CANNOT BE HELD RESPONSIBLE FOR ANY PREVIOUS MEDICAL CONDITIONS THAT I MAY HAVE. E. I UNDERSTAND THAT THE UNIVERSITY AND THE DEPARTMENT OF ATHLETICS WILL NOT PAY FOR SECOND OPINIONS THAT ARE NOT APPROVED BY THE UNIVERSITY’S HEAD ATHLETIC TRAINER. F. I UNDERSTAND THAT IF A MEDICAL SERVICE IS TO BE PAID FOR BY THE UNIVERSITY OF SOUTH ALABAMA, IT WILL BE PERFORMED BY THE UNIVERSITY OF SOUTH ALABAMA MEDICAL STAFF UNLESS OTHERWISE APPROVED BY THE UNIVERSITY’S HEAD ATHLETIC TRAINER.



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AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

TO: All Universities, Colleges, High Schools, Physicians, Athletic Trainers, Hospitals,

Clinics, Dispensaries, and all other health care agencies.

REQUEST FROM: _____________________________________________ (Provider/Physician)

ADDRESS: Andy Harcourt, MD or Albert W. Pearsall, MD University of South Alabama Athletic Department 6001 USA Drive South, Suite 35 Mobile, AL 36688-0002

Fax #: 251-445-9568 (Football) or 251-460-7607 (HPELS)

DATE: ____________________

INFORMATION REQUESTED: PURPOSE OF REQUESTED INFORMATION: _____ Complete Medical Record _____Patient Request _____ Immunizations _____ Continued medical care _____ Labs _____ Other: _____ Diagnostics (MRI, CT, X-ray) _____ Other:

STUDENT- ATHLETE – PLEASE COMPLETE THE BELOW INFORMATION:

Patient Name: ____________________________________________________________________ First Middle Last Date of Birth _____/_____/______SSN: _____-_______-________Sport: __________________ Jag #: _______________ You are hereby authorized and requested to send a complete copy of all your records pertaining to my medical condition, including all physical athletic trainer’s records, any diagnosis, treatment, history, prognosis, from your personal knowledge and/or records for the purposes of obtaining a complete medical history and record on the above named individual. Student Signature: _________________________________________ DATE ____/____/____ Parent or Guardian Signature _________________________________ DATE ____/____/____ (Required if student athlete is under 19 years of age)


Sickle Cell Trait Information Sheet/Waiver Revised February 2011

Sickle Cell Trait Testing: The NCAA requires that all Division I student-athletes who are beginning their initial year of eligibility and student athletes

trying out for an intercollegiate team, including transfer student-athletes to complete a sickle cell solubility test, show results of a prior test, or sign a waiver releasing the school from liability if they decline to be tested. Sickle cell solubility test results or waiver must be completed before participating in athletic-related activities, including intercollegiate athletics events, strength and conditioning sessions, tryouts, practices, or competitions. Division I Bylaw 17.1.5.1

Please insert your name, date of birth, and sport below then select one of the options below and return this form and the supporting documentation. Name _________________________________ _____________________________ _________________ Last First Middle Sport(s): ____________________ SS# _______-________-________ Date of Birth ___/___/___State of Birth: ________________ Mother’s Maiden Name: ________________________________ Mother’s Date of Birth ___/___/___

Please choose ONE of the following: A._____ I would like to be tested by the USA sports medicine staff as part of my pre-participation physical examination. I understand that there may be a delay in my medical clearance and that the results will be shared with the team physician. IF YOU CHOSE THIS OPTION YOU MUST SIGN OPTION A BLOOD SOLUBILITY TESTING BELOW. OPTION A Sickle Cell Solubility Test (only needed if Blood Solubility Testing is selected above): I hereby authorize the University of South Alabama Sports Medicine staff to obtain a blood screen, and to use, disclose, or obtain protected health information (PHI) from my medical record. This consent and authorization may include, but is not limited to the release of psychological, psychiatric, alcohol, drug abuse, HIV/AIDS, and sickle cell information. I hereby grant permission to the University of South Alabama athletics and consulting physicians to store my medical information within the department of athletics in my medical records, and at the USA comprehensive sickle cell center on the database. Student Signature: _________________________________________ DATE ____/____/____ Parent or Guardian Signature _________________________________ DATE ____/____/____ (Required if student athlete is under 19 years of age) B._____ A copy of my newborn screening records pertaining to sickle cell trait are attached – C._____ A copy of my sickle cell trait test from a physician or other authorized medical care provider is attached. D._____ The University of South Alabama Sports Medicine staff has a copy of my sickle cell trait test. E.______ (Tryout Participants Must be Tested – You Cannot Select this Option)I voluntarily decline to be tested, understand that an undiagnosed trait can be dangerous, even fatal, and agree to sign the waiver below. IF YOU CHOSE THIS OPTION YOU MUST SIGN THE OPTION EWAIVER BELOW. OPTION E- Sickle Cell DECLINE Testing Waiver(only needed if option “E” is selected above): I, _____________________________________________, understand and acknowledge that the NCAA requires that all Division I student-athletes who are beginning their initial year of eligibility and student athletes trying out for an intercollegiate team, including transfer student-athletes to complete a sickle cell solubility test, show results of a prior test, or sign a waiver releasing the school from liability. I decline to be tested before participating in athletic-related activities. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or other disabilities experienced. I hereby affirm that I have fully disclosed in writing any knowledge of sickle cell trait status to the USA Sports Medicine Department. I do not wish to undergo sickle cell testing as part of my pre-participation physical exam and I voluntarily agree to release, discharge, indemnify and hold harmless the State of Alabama, Alabama Board of Trustees, USA Athletics and University of South Alabama, their respective officers, coaches, associated medical staff, instructors, agents or employees from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my voluntary decision not to be tested. I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full knowledge of its significance. If I am under 19 years of age, my parent and/or guardian has also signed below. Student Signature: _________________________________________ DATE ____/____/____ Parent or Guardian Signature _________________________________ DATE ____/____/____ (Required if student athlete is under 19 years of age)

14University of South Alabama

ADD/ADHD Medical Documentation

The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in competition. Some legitimate medications contain NCAA banned substances, and student athletes may need to use these medicines to support their academics and their general health. The NCAA has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The diagnosis of adult ADD/ADHD remains clinically based utilizing clinical interviews, symptom-rating scales, and subjective reporting from patients and others. Student-athletes diagnosed with ADD/ADHD require certain medical records on file in order to request an exception in the event of testing positive during an NCAA Drug Test. Please answer the following questions by circling the correct response:

1. Have you ever been diagnosed with ADD/ADHD? Yes No

2. If so, were you diagnosed during childhood? N/A Yes No

3. Are you taking any medication for this condition? N/A Yes No If you answered YES to any of the above questions please obtain documentation from treating physician and submit the following information:

□ Description of the evaluation* process which identifies the assessment tools and procedures for this diagnosis.

□ Statement of the diagnosis, including when it was confirmed.

□ History of ADD/ADHD treatment (previous/ongoing).

□ Statement that a non-banned ADD/ADHD alternative has been considered if a stimulant is currently prescribed.

□ Copy of the most recent prescription (as documented by the prescribing physician). All of the aforementioned information may be reported in the form of a dictated letter from your prescribing physician. Student-athletes treated since childhood with stimulant medication but who do not have records of childhood assessments, or who are initiating treatment as an adult, must undergo a comprehensive evaluation to establish a diagnosis. These evaluations may be done on- campus through the USA Psychology Clinic @ (251) 460-7149.

I,_____________________(first and last name), hereby acknowledge that the University of South Alabama Sports Medicine Staff has informed me of the procedure to review and approve legitimate use of medications prescribed to me for ADD/ADHD. I understand that not following this procedure while taking these medications can lead to a positive drug test for the NCAA and South Alabama institutional testing and the consequences that go along with it.




Consent to Drug Testing and Authorization for Release of Information

I herby consent to have a sample(s) of my urine or other approved substance collected and tested for the presence of

certain drugs and substances in accordance with the provisions of the University of South Alabama Alcohol and

Drug Education and Testing Program. I acknowledge that I understand the following methods of specimen

collection may be utilized; urine sample, hair sample, or oral swab sample for drug analysis as a part of the

university drug testing program related to my 2015-2016 NCAA intercollegiate participation. I have been informed

and understand the University of South Alabama Athletic Department’s Alcohol and Drug Education and Testing

Program. The student athlete agrees to comply with the requirements of the policy and consent to observed drug and

alcohol screening as provided in such policy.

I also authorize the release of any confidential information or test results to; team physician, athletic director,

designees of the University of South Alabama Alcohol and Drug Testing Committee, my parents or legal guardians,

head coach or the position coach of any intercollegiate sport in which I am a team member, and designee of the

University of South Alabama Substance Abuse Counseling Center within the parameters set forth in the

aforementioned policy. The student athlete understands that compliance with the policy is a condition of his/her

continued eligibility to participate in practice, conditioning activities, and/or competitions for the University of South

Alabama, Department of Athletics. The student athlete understands the disciplinary actions set forth in this policy

that can be taken with regard to his/her participation in intercollegiate athletics.

The University of South Alabama, its Board of Trustees, its officers, employees and agents are hereby released by

the student athlete from any legal responsibility for the release of such information and records as authorized by this

form.

I have read, understand, and am willing to comply with the University of South Alabama Alcohol and Drug

Education and Testing Program. I have also been given the opportunity to ask questions and have had my questions

answered satisfactorily. I understand that signing this form is a contingency for my participation in intercollegiate

athletics at the University of South Alabama.




Concussion and Illness Reporting Acknowledgement Form

A concussion is a brain injury that: Is caused by a blow to the head or body.– From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball, can change the way your brain normally works, can range from mild to severe, presents itself differently for each athlete, can occur during practice or competition in ANY sport, can happen even if you do not lose consciousness.

What are the symptoms of a concussion? Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise.

• Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time.

Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse.

I, ___________________________, acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct responsibility for reporting all of my injuries and illnesses to the sports medicine staff of my institution (e.g., team physician, athletic training staff).

I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced.

I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution.

I further understand that there is a possibility that participation in my sport may result in a head injury and/or concussion.

I have been provided with education on head injuries and understand the importance of immediately reporting symptoms of a head injury or concussion to my sports medicine staff.

By signing below, I acknowledge that my institution has provided me with specific educational materials on what a concussion is and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue. I understand that the Sports Medicine department will provide baseline neuropsychological screening (Impact Testing) for sports of baseball, basketball, football, pole vaulting, soccer, and softball, which have been identified as collision or contact sports or who have a previous history of concussions as detailed on their health history questionnaire. The IMPACT™ system will be used which consists of specific modules designed to test cognitive functioning. I also understand that the following tests may also be utilized: cognitive and physical evaluation (Modified SAC Assessment), and a Balance Examination – (BESS). I have read the above and agree that the statements are accurate and true.



17

University of South Alabama Student-Athlete Concussion Statement

☐ I understand that it is my responsibility to report all injuries and illnesses to my athletic trainer and/or team physician.

☐ I have read and understand the NCAA Concussion Fact Sheet.

After reading the NCAA Concussion fact sheet, I am aware of the following information:

Initial

A concussion is a brain injury, which I am responsible for reporting to my team physician or athletic trainer.

Initial

A concussion can affect my ability to perform everyday activities, and affect reaction time, balance, sleep, and classroom performance.

Initial

You cannot see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

Initial

If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or athletic trainer.

Initial

I will not return to play in a game or practice if I have received a blow to the head or body that results in concussion-related symptoms.

Initial

Following concussion the brain needs time to heal. You are much more likely to have a repeat concussion if you return to play before your symptoms resolve.

Initial

In rare cases, repeat concussions can cause permanent brain damage, and even death.



18

University of South Alabama Department of Athletics Policy Statement & Disclosure Form on Dietary Supplements

The University of South Alabama does not condone the use of dietary supplements for the purpose of performance enhancement and/or muscle building. Dietary supplements do not currently undergo federal government approval and are not tested for quality like prescription and over-the-counter medications. The product claims made by many dietary manufacturers have not been based upon independent research. The potential adverse and/or harmful effects of these substances have not been completely studied, yet serious adverse effects have been reported in some instances. Some products may contain NCAA and/or University banned substances which are not listed on the label. The University recognizes that some banned substances are used for legitimate medical purposes. Accordingly, the University allows exceptions to be made for those student-athletes with a documented medical history demonstrating a need for regular use of such a substance. Exceptions may be granted for such substances by the permission of the Team Physician only. The student-athlete has the responsibility to inform the medical staff of such medications that he/she may be taking. The University should maintain in the student-athlete’s medical records a letter from the prescribing physician that documents the student-athlete’s medical history demonstrating the need for regular use of such a drug. In the event that a student-athlete were to test positive by an NCAA or University drug test, the Head Athletic Trainer and the Team Physician will review the student-athlete’s medical record to determine whether to grant a medical exception from the institution or seek one from the NCAA. By signing this form the student-athlete/guardian acknowledges that:

1. He/she has been educated and fully understands the NCAA and University policies regarding the use of supplements and fully accepts the detrimental and possibly permanent defects caused by the use of dietary supplements, including the loss of eligibility caused by a positive drug test due to the presence of a banned substance in a dietary supplement.

2. He/she agrees to disclose all dietary supplements used, to a member of the athletic training staff or team physician.

3. He/she accepts any and all liability if he/she has in the past used, continues to use and/or uses at anytime in the future, dietary supplements in any form; and releases the University of South Alabama, its Trustees, officers, employees, and agents, together with all persons assisting with any phase of the program, from all liability and responsibility for any loss or injury related to the student athlete’s use of dietary supplements.

I, _________________________, would like to disclose the following substance which I consume as a dietary

supplement. I understand that labeling on these products can be misleading and inaccurate, and that advice of sales

personnel may be inaccurate. Terms such as “healthy” or “naturally occurring” do not necessarily imply safety nor does it

imply that the NCAA or the University approves these substances. Ultimately, I agree that I AM RESPONSIBLE FOR

KNOWING WHAT IS CONTAINED IN SUPPLEMENTS AND WHAT SUBSTANCES I PUT IN MY BODY.

Brand Name: _____________________________________ Description: _________________________________

Brand Name: _____________________________________ Description: _________________________________



19CATASTROPHIC BENEFICIARY DESIGNATION

As an insured intercollegiate student athlete enrolled at the University of South Alabama, the USA Department of

Athletics is pleased to provide you with Catastrophic Injury coverage through the NCAA. Under this coverage, as

an insured student athlete you are provided with accidental death benefits while participating in intercollegiate sports

at the University of South Alabama.

The purpose of this beneficiary designation is to provide you your right under the policy to designate a beneficiary to

whom any death benefit shall be payable and, at your option, the beneficiary designation may be changed by you at

any time.

DESIGNATION OF BENEFICIARY

If I,_________________________________, do not name a beneficiary or if my named beneficiary does not survive

me, I understand that the payment of any benefits will be made to my estate, or at the option of the underwriting

company, to the following:

a). My spouse, if living; otherwise

b). My then living children, if any; otherwise

c). My surviving parent(s); otherwise

d). My surviving brothers and sisters, equally.

I name as beneficiary(ies) the person(s) named below:

____________________________________ ____________________________ Name of beneficiary Relationship

____________________________________ ____________________________

Name of beneficiary Relationship

EXECUTED this________ day of_______________________, 20______.



20

INSURANCE AND FINANCIAL RESPONSIBILITY ALL UNIVERSITY OF SOUTH ALABAMA INTERCOLLEGIATE STUDENT-ATHLETE PARTICIPANTS MUST BE COVERED BY A MAJOR MEDICAL HEALTH INSURANCE THAT HAS BEEN APPROVED BY JAGUAR ATHLETICS BEFORE PARTICIPATING IN ANY PRACTICE, GAME, AND/OR COMPETITION. The student-athlete’s health insurance policy must cover PARTICIPATION in intercollegiate athletics and have an inclusion for intercollegiate athletic related injuries and/or illnesses, and shall be considered the PRIMARY insurance coverage for all athletic related injuries. Some insurance companies may be impermissible due to the compatibility with the athletic institutional excess athletic coverage, (i.e. TRICARE, KEISER, MEDICAID). Please discuss with the sports medicine staff if you have any questions. The student-athlete must complete a Health Insurance Information / Authorization Form and supply a photocopy (front & back) of the health insurance card on a yearly basis. South Alabama Athletic Department carries an excess accident medical insurance which provides excess medical coverage for injuries incurred by student-athletes while participating in an intercollegiate sponsored /supervised activity. The student-athlete is required to have primary insurance through another source; the excess accident medical policy applies toward those expenses not covered by the primary policy. Mutual of Omaha is the insurer and claims manager for this program. The Master Policy on file at the University contains all of the provisions, limitations, exclusions, and qualifications. If any discrepancy exists between this brochure and the Policy, the Master Policy will govern and control the payment of benefits. THIS POLICY, HOWEVER, IS SECONDARY TO, OR IN EXCESS OF, PERSONAL FAMILY MEDICAL INSURANCE COVERAGE, and covers ONLY injuries / illnesses / accidents resulting from the direct participation in the intercollegiate athletics program during the dates of the primary competitive season and designated off-seasons as approved by the Director of Athletics according to NCAA regulations. The policy provisions include a benefit period for 104 weeks (2years) from the documented time of injury. No benefits will be paid beyond the policy limits. The NCAA provides a catastrophic insurance program for student-athletes.

Exclusions and Limitations: University of South Alabama’s secondary medical insurance policy WILL NOT apply to the situations indicated below. This list is not all-inclusive.

1. Injuries / Illnesses that are not the direct result of intercollegiate athletics participation during the dates of the primary competitive season and designated off-seasons as approved by the Director of Athletics according to NCAA

2. Experimental procedures or Cosmetic surgery or procedures unless directly related to an athletic related injury 3. Injuries / illnesses that are a result of intramural, club sports, and recreational activities (non-intercollegiate activities), as well as training /

conditioning activities that occur outside of the primary competitive season and designated off-season periods. 4. Injuries / illnesses that are recurrences of old injuries / illnesses which were sustained before participation in the intercollegiate sports

program, or expenses for athletic injuries incurred after completion of the student-athlete’s intercollegiate athletic eligibility. 5. Medical expenses beyond the limitations and exclusions of, or not covered by the University of South Alabama Department of Athletics

insurance policy.

The importance of having some form of personal major medical health insurance coverage cannot be overemphasized. Medical bills resulting from the aforementioned activities will be submitted to the student-athlete’s primary medical insurance. Any unpaid balances are the responsibility of the student-athlete and/or the student-athlete’s parent(s) / guardian(s)

Compliance with Insurance Company Requests: It is the student-athlete’s and his/her parent(s) / guardian(s) responsibility to understand the conditions that apply to their policy and comply with any request for information, etc. from the primary insurance company. Insurance companies request information on their policy holders when injury / illness medical claims are billed. Examples are, but not limited to, accident/injury questionnaires mailed to your home asking you to answer and mail back to the insurance company and/or student enrollment verification, proving he/she is in college. Any delinquent bills resulting in bad credit due to non-compliance with insurance company requests will be the responsibility of the student-athlete. In the event that a student-athlete and/or his/her parent(s) / guardian(s) receives payment / reimbursement directly from their insurance company for athletic related injury / illness claims, the full account balance becomes the responsibility of the student-athlete and/or his/her parent(s) / guardian(s), until payment is turned over to the provider.

HMOs If a student-athlete’s primary insurance is an HMO, the University of South Alabama Athletic Training Department strongly encourages the student-athlete and/or his/her parents(s) / guardian(s) to change the primary care physician (PCP) to a University of South Alabama Team Physician or local physician who is possibly in your network. Some HMO policies have “away from home care” when the student-athlete is out-of-network. Please call your insurance company’s customer service department for questions and relocation of your PCP. This will allow the student-athlete to have a network of physicians in the South Alabama area, as well as better access to care.

Insurance Policy Changes: University of South Alabama Athletic Training Department must receive any changes to a health insurance policy as soon as they occur. If proper notification is not received, the University of South Alabama Athletic Training Department will not be responsible for any delays in payment, collections notices, credit reports, etc. that occur. If a cancellation of a policy occurs without proper notification, all bills incurred during that period will be the responsibility of the student-athlete and/or his/her parents(s) / guardian(s).

Medical Bills: In the event that a student-athlete should receive a bill / statement for an injury / illness that occurred as a direct result of participation in intercollegiate athletics at University of South Alabama, the student-athlete must submit the bill / statement to his/her certified athletic trainer Bills received after 20 business days will be the responsibility of the student athlete and/or the student athlete’s parents(s)/guardian(s). I understand and acknowledge the above provisions related to primary insurance coverage, changes, and out of network provisions. Student- Athlete Name: _____________________________________ Sport: _____________ Student Signature: _________________________________________ DATE ____/____/____

21Parent or Guardian Signature _________________________________ DATE ____/____/____ (Required if student athlete is under 19 years of age)

University of South Alabama Sports Medicine Medical Insurance Information

(To be completed by student athlete’s parent or guardian) Athlete’s Name: _______________________________________________ D.O.B.: ______________________

Social Security #:_____________________ Jaguar ID: _________________ Sport(s):__________________________

A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD(S) IS MANDATORY

PARENT/GUARDIAN INFORMATION

Father/Guardian: _______________________________ Mother/Guardian: ____________________________

Social Security #: _______________________________ Social Security #: ____________________________

Address: ______________________________________ Address: ___________________________________

________ ____________________________________ __________________________________________

Home Phone:__________________________________ Home Phone: ________________________________

Cell Phone: ____________________________________ Cell Phone: __________________________________ Employer: _____________________________________ Employer: ___________________________________ Address: ______________________________________ Address: ____________________________________ _____________________________________________ ____________________________________________ Work Phone: ___________________________________ Work Phone: _________________________________ PRIMARY INSURANCE (REQUIRED FOR PARTICIPATION) SECONDARY INSURANCE

Insurance Carrier:_______________________________ Insurance Carrier: _____________________________

Name of Insured: _______________________________ Name of Insured: _____________________________

D.O.B.: _______________________________________ D.O.B.: _____________________________________

Policy Number: _________________________________ Policy Number: ______________________________

Group/Plan Number: _____________________________ Group/Plan Number: __________________________

Effective Date: __________________________________ Effective Date: _______________________________

Insurance Co. Address: ___________________________ Insurance Co. Address: ________________________

___________________________ __________________________________________

Insurance Co. Phone Number: _______________________ Insurance Co. Phone Number: ___________________

Is this plan an: HMO?Y ( ) N ( ) PPO? Y ( ) N ( ) Is this plan an: HMO? Y ( ) N ( ) PPO? Y ( ) N ( )

Does your insurance require out of network “Away from home” or “Guesting” Certification? Y( ) N ( )

THE FOLLOWING AUTHORIZATION MUST BE SIGNED BEFORE WE CAN FILE A CLAIM WITH YOUR

HEALTH INSURANCE CARRIER OR THE SECONDARY ATHLETIC INSURANCE CARRIER. _____ I hereby authorize the University of South Alabama Department of Athletics to file a claim on my behalf for the athletic

injury/illness sustained by (dependent) under the above group medical policy. I confirm that my medical health insurance provides benefits for claims in the Mobile area. Further I agree and consent that any amounts payable under this policy may be paid to the medical provider.

_____ My son/daughter is not covered under my, or their own, personal health insurance. I understand that my son or daughter

will not be allowed to participate in intercollegiate athletics without valid medical health insurance. Student athletes that are scholarship and grant- in- aid recipients can apply for funds that may be available through the student athlete opportunity fund for valid health insurance. Applications are available from the sports medicine department. Therefore, I authorize the University of South Alabama, Department of Athletics to inspect or secure copies of case history, lab reports, diagnosis, x-rays, and any other information related to this claim, and I understand that I will incur all financial responsibility for medical claims due to my son or daughter not being covered under a health plan or that my health plan will not be valid in the Mobile, AL area.

22 ____________________________ __________________________ _______________

Signature of Parent/Guardian Signature of student athlete Date signed

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