Dear Student-Athlete, Welcome to the Lumberjack family, we are excited to have you join us! In order to participate in athletics here at SFA the Sports medicine department has several requirements to insure that your health and wellbeing are taken care of. Failure to complete these steps will result in a loss of practice or training sessions. Please complete all of the steps below- if you have any questions please contact your coach or your Athletic Trainer. Please have all of these steps completed below to ensure that there is no delay in your athletic participation. Thanks and Axe’em Jacks SFA Sports Medicine Department

AJ Van Valkenburgh- Director of Sports Medicine Cell : 936-615-3134 Office Phone: 923-468-4550 Email: vanvalkeaj@sfasu.edu

SFA Sports Medicine Contact Info: Phone: 923-468-4550 Fax: 936-468-4052

Phase 1: Sports Medicine Student Profile Creation (in order to complete these steps you must have an SFA Student ID number or Social Security Number): ** If you do not have a student ID number or a Social Security Number please notify the Director of Sports Medicine immediately – Cell - 936-615-3134**

1. Please log in on a computer or your smartphone to the following website https://blueocean.edh.com at the bottom of the page there will be a blue link that says Need Help? / New User Registration please click on this link and follow three simple steps:

i. Steps 1 – Enter School Code (ALL CAPS) – STEADS also verify that you are not a robot so that you can move on to Step 2.

ii. Step 2 – Please fill in all fields/boxes with a red asterisk *

iii. Step 3 – Fill out all demographic information in this step and press submit. This will send out a notification to our office that you have created your profile and will notify us that you need to be approved.

2. After completing the steps above you need to notify you’re the Director of Sports Medicine through email that this has been completed – vanvalkaj@sfasu.edu. Once you have notified the Director of Sports Medicine that said steps are complete within 24-48 hours a Link will be sent to your personal email account provided or to newly created student email account with a temporary username and password. You will need to log in with this username and password and then change your password to something that you can remember. If you do not receive an email with this information please contact the Director of Sports Medicine.

Phase 2: Custom Signature Forms Step 1: Please login to your account on https://blueocean.edh.com

Step 2: On the left hand side of the page, 15 lines down click on Forms. Step 3: Please click on the tab labeled Pending List and Select New Physical Packet- this will pull up a pop-up box for many pages of information that needs to be read, as well as electronic signatures in each box with a red * next to it. Please supply an answer to all questions, or enter N/A if not applicable.

Phase 3: General Medical Physical Instructions Step 1: Attached to the initial email you received with instructions you will find a document labeled (New Athlete GenMed Physical) this can also be accessed through our Pre Participation Physicals Process Button on the Sports Medicine home page found on https://sfajacks.com. Step 2: Open or download the document titled New Athlete GenMed Physical, this will be a PDF document that can be printed and filled out hand written. Step 3: Fill out all required general medical and orthopedic history (pages 1-8) – this will enable your doctor to go over all of your pertinent medical history to date.

1. After filling out pages 1-8 and then print this document in its entirety it will be taken to Doctor’s office for physical.

2. No other form of this physical will be accepted except the forms provided by SFA Sports Medicine on this website. *All Physicals must be performed by the following Providers/Doctors: MD, DO, and Nurse Practitioner. Chiropractors, Physical therapist, Occupational Therapist, etc. will not be accepted as physicians for this exam.*

3. Have your Doctor fill out pages 9-11 of the New Athlete General Medical History and Physical exam document

4. Fax document (from doctor’s office) to 936-468-4052 or scan and email the document to your respective athletic trainer’s email. Your athletic trainer will respond to let you know within 48hrs that they have received your physical packet.

Phase 4: Sickle Cell Testing Procedures Sickle Cell Testing – All student athletes are required by SFA to know their sickle cell status and provide results of a sickle cell blood test before participation. There are several ways to obtain this information:

Option A – Have your physician that you are going to for your physical examination order the Sickle Cell blood work testing and draw blood during your physical. You can notify your physician that this test is NCAA mandated. This option will have some cost associated possibly, all results must be faxed or emailed to SFA and include actual lab results (no letters from physician will be accepted). Option B – Http://Personallabs.com which will link you with a lab in your area to have the blood drawn. This option will have a cost associated and all results must be faxed or emailed to SFA and include actual lab results. Option C – If you have had a sickle cell test preformed at another university you may obtain these records from said university and have them faxed to SFA – ( We will not contact said University for you) Option D – Wait to have blood work done once you arrive on campus, this option will result is missing a minimum of 2 days of training/practice. ( if this is the option your desire you will need to contact your coach so that they can let your athletic trainer know about your on campus needs)

All obtained sickle cell results must be faxed immediately to the SFA Sports Medicine Staff. Do not wait to bring to campus. Fax 936-468-4052

Phase 5: Health Insurance Verification All forms regarding verification of insurance on the Sports Medicine Student Profile should have been completed in Phase 1.

Steps 1 – You will then need to download the phone App on your smart phone. ii. NExTT Pic – Please search for this app and proceed with your download.

iii. Open App – it will ask you for your school name (Stephen F. Austin State

University) Student Name ( Your Name) Student ID/DOB ( Either your school student ID or your student Date of Birth) – then Press Continue

iv. The app will then prompt you to capture images of front/back of your health insurance card. This is a similar process to how you may deposit a check with you bank account.

v. Then press Submit.

Step 2 – You will be contacted by our insurance specialist (Nicole Moore) if any other info is needed by you or the policy holder to help in the health insurance verification process. If you have any issues uploading your health insurance information please contact your athletic trainer immediately.

Phase 6: Athletic Training Room - Orthopedic Screen Procedures This is your final destination to competing and practicing with you team. You will not be able to attend any mandatory or voluntary team activities to include (weights / run sessions / OTA’s / Pickup games etc.) with you team without this final step. You will report for your orthopedic exam with your designated Athletic Trainer prior to the first day of training. You will be contacted by your Athletic Trainer or Coach with information on the date, time, and location of these exams. Note* - if you have had surgery in the last five years you must provide documentation for these procedures prior to the start of this exam.

vi. This must be completed prior to participation in any activity. vii. The orthopedic exam will not be scheduled if prior steps are not completed, no

exceptions. viii. There is the possibility that you will not be cleared for participation due to

orthopedic concerns found during this exam. If this is the case further testing will be ordered and your coach will be apprised of your status.

ix. Another orthopedic exam from any outside provider will not be permitted to take the place of the ATR – Orthopedic Screen

Athlete Name:__________________ DOB:_____________ Sport:_______________

STEPHEN F. AUSTIN STATE UNIVERSITY MEDICAL AND ORTHOPEDIC HISTORY

General Medical Have you been under the medical care of a physician at any time in the PAST THREE YEARS? Yes No If yes, please explain:______________________________________ Have you been hospitalized for any reason in the PAST THREE YEARS? Yes No If yes, please explain: __________________________________________ Allergies – Are you allergic to any of the following: Aspirin Yes No Any Foods Yes No Codeine Yes No Any Other Drug Yes No Sulfa Yes No Tetanus Antitoxin or Serums Yes No Penicillin Yes No Novocain or Other Anesthetics Yes No Hay fever Yes No Other Seasonal Yes No Asthma: Have you ever experienced unexplained shortness of breath during exercise? Yes No Have you ever been told you have asthma? Yes No Have you ever been prescribed an inhaler? Yes No If yes, what type of inhaler: _________________ Have you ever had activity restrictions due to asthma or breathing troubles? Yes No If yes, please explain:____________________________ Heat Related Problems: Have you ever experienced any of the following: When Where Heat Exhaustion Yes No Heat Cramps Yes No Heat Stroke Yes No Explain the treatment you received for any of the above problems: Have you ever been hospitalized for a heat related problem? Yes No If yes, please explain:

Athlete Name:__________________ DOB:_____________ Sport:_______________

Other Diseases and Illnesses – Do you or have you ever had any of the following: High Blood Pressure Yes No Hemorrhoids Yes No Frequent Headaches Yes No Hernia Yes No Migraine Headaches Yes No Kidney or Bladder Infections Yes No Migraine medication:_____________ Frequent Sore Throats Yes No Kidney or Bladder Stones Yes No Infectious Mononucleosis Yes No Gout Yes No Myocarditis Yes No Delayed or missed period Yes No Glandular Fever Yes No Diabetes Yes No Ear Disease Yes No Epileptic Attacks/Seizures Yes No Absent Organ Yes No Medication if needed:__________________ Pneumonia Yes No Hearing Trouble Yes No Heart Murmur Yes No Frequent Respiratory Infections Yes No Ulcer Yes No Frequent Skin Infections Yes No (i.e. rash, fungus, blisters, Staph) Malaria Yes No Fainting Yes No Appendicitis Yes No Hepatitis Yes No Frequent Diarrhea Attacks Yes No Hearing Trouble Yes No Congenital Generalized Mental Illness Yes No Abnormalities Yes No If Yes: False Eye Yes No Hearing Aid Yes No

Medications You Take: List ALL medications (prescription and over the counter) you are CURRENTLY taking or have taken over the PAST 3 MONTHS and for what purpose: MEDICATION DOSAGE PURPOSE

Athlete Name:__________________ DOB:_____________ Sport:_______________

ADD/ADHD: Have you ever been told you suffer from an attention disorder (ADD/ADHD)? Yes No Have you ever been prescribed medication for an attention disorder? Yes No If yes please give medication, dosage, and prescribing doctor’s information: _____________________________________________________________________________________ Mental Health Have you ever experienced any of the below: -Depression -Anxiety -Excessive stress -Suicidal thoughts -Bipolar disorder -Eating disorder -Sleep disorder

If yes please explain: _________________________________________________________________ Are you or have you ever taken medication for a mental disorder or disease?

If yes please give medication, dosage, and prescribing doctor’s information:

___________________________________________________________________________________ Concussion

Have you ever suffered from a concussion, had your bell rung, saw spots after a hit?

If yes please explain below:

Year Games/Days missed Year Games/Days missed Year Games/Days missed Year Games/Days missed

Do you have any lingering symptoms from a concussive event?

If yes please explain:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Athlete Name:__________________ DOB:_____________ Sport:_______________

Surgery – Operations

List ALL previous surgeries beginning with the most recent: 1. Operational Procedure: Body Part: Date: Physician Name: Physician’s phone number: 2. Operational Procedure: Body Part: Date: City and Hospital: Physician’s phone number: 3. Operational Procedure: Body Part: Date: Physician Name: Physician’s phone number: 4. Operational Procedure: Body Part: Date: Physician Name: Physician’s phone number: 5. Operational Procedure: Body Part: Date: Physician Name: Physician’s phone number: 6. Operational Procedure: Body Part: Date: Physician Name: Physician’s phone number:

Athlete Name:__________________ DOB:_____________ Sport:_______________

Orthopedic History

Have you ever had any of the following: Head/Neck Pinched Nerves Yes No Fractures Yes No Sprains Yes No Pain Yes No Burners/Stingers/pinched nerve Yes No Calcium Deposits Yes No

Spine/Back Fractures Yes No Muscle Spasm Yes No Stiffness Yes No Pain with Lifting Yes No Pain Yes No Scoliosis Yes No Ruptured/herniated disc Yes No Location: _________________

UPPER BODY Shoulder/Clavicle Have you ever been told you had a rotator cuff sprain/strain? Yes No (R / L) Have you ever been told you have a labral tear? Yes No (R / L) Have you ever had pain with overhead activity (pull-ups, push-ups, throwing, bench press, etc.)? Yes No (R / L) Fracture Yes No (R / L) Numbness in Arms or fingers Yes No (R / L) Separation of shoulder Yes No (R / L) Dislocation/slipping of shoulder Yes No (R / L) Burner/stinger Yes No (R / L) Inflammation of shoulder Yes No (R / L) Impingement in shoulder Yes No (R / L) Pain Yes No (R / L) Elbow/Arm Sprain Yes No (R / L) Hyperextension Yes No (R / L) Dislocation Yes No (R / L) Fracture Yes No (R / L) Pain Yes No (R / L)

Athlete Name:__________________ DOB:_____________ Sport:_______________

Hands, Wrists and Fingers Fractures Yes No (R / L) Sprains Yes No (R / L) Dislocations Yes No (R / L) Navicular Fractures Yes No (R / L) Pain Yes No (R / L) Have you suffered from an upper body injury within the past 3 years that removed you from sport for more than 2 weeks? Yes No Have you had any imaging taken of your upper body in the past 3 years? Yes No Please give detail of, and explain any tests or treatments you received, for any of the above conditions: (Example – Condition: rotator cuff tear; Tests: MRI, CT Scan, X-Ray, etc.; Treatment: surgery, physical therapy)

Athlete Name:__________________ DOB:_____________ Sport:_______________

Lower Body

Hip/Pelvis Torn Ligament Yes No (R / L) Torn Labrum Yes No (R / L) Impingement Yes No (R / L) Strain/Sprain Yes No (R / L) Groin/hip flexor pulls Yes No (R / L) Contusion/hip pointer Yes No (R / L) Fracture Yes No (R / L) Dislocation Yes No (R / L) Pain Yes No (R / L)

Thigh Torn Muscles Yes No (R / L) Fractures Yes No (R / L) Calcium deposits Yes No (R / L) Numbness Yes No (R / L) Quad Pulls Yes No # In the past 2 years: Left Right _______

Hamstring Pulls Yes No # In the past 2 years: Left Right

Knees Sprained Ligaments Yes No (R / L) If Yes, which ligaments? Torn Ligaments Yes No (R / L) Torn ACL Yes No (R / L) Torn cartilage/meniscus Yes No (R / L) Injured Knee Caps Yes No (R / L) Fractures Yes No (R / L) Dislocations Yes No (R / L) Swelling Yes No (R / L)

Locking Yes No (R / L) Giving away/instability Yes No (R / L) Pain Yes No (R / L) Athrograms Yes No (R / L) Arthroscopes Yes No (R / L) Tendonitis Yes No (R / L) Osgood-Schlater’s Disease Yes No (R / L) Wear Braces Yes No (R / L)

Lower Legs Fractures Yes No (R / L) Shin Splints Yes No (R / L) Sprains Yes No (R / L) Torn Muscles Yes No (R / L) Calcium Deposits Yes No (R / L) Pain Yes No (R / L)

Ankle Sprains Yes No # In the past 2 years Left Right

Dislocations Yes No (R / L) Fractures Yes No (R / L) Pain Yes No (R / L) Achilles tendon injury Yes No (R / L)

Athlete Name:__________________ DOB:_____________ Sport:_______________

Feet/Toes Fractures Yes No (R / L) Sprains Yes No (R / L) Dislocations Yes No (R / L) Turf Toe Yes No (R / L) Numbness/tingling Yes No (R / L) Have you ever had a sports hernia? Yes / No If Yes, please describe: Have you ever been told by a physician or athletic trainer that you have an arthritic or degenerative condition? Yes / No

If Yes, please describe:

Do you use orthotics or prosthetics? Yes / No If Yes, please describe: Have you suffered from a lower body injury within the past 3 years that removed you from sport for more than 2 weeks? Yes No Have you had any imaging taken of your lower body in the past 3 years? Yes No Please give detail of, and explain any tests or treatments you received, for any of the above conditions: (Example – Condition: turf toe/left foot; Tests: MRI, CT Scan, X-Ray, etc.; Treatment: surgery, physical therapy)

Athlete Name:__________________ DOB:_____________ Sport:_______________

STEPHEN F. AUSTIN STATE UNIVERSITY

Medical Examination Name:__________________________ Sport:__________ Date of Exam:____________ Date of Birth:____________ Age:______ Height:_________ Weight:_________ Sex:_____

TO BE FILLED OUT BY PHYSICIAN ONLY!! N=NORMAL AB=ABNORMAL N AB COMMENTS

HEAD Hair, Scalp, Masses

EYES Lids, Conjunctiva, Sclera, EOM, Proptosis, Pupils, Peripheral Vision, Fundi, Gross Tension to Palpation

Vision Right: 20/_____ Left: 20/_____ (corrected or uncorrected)

EARS Gross Hearing to Speech, Discharge, Drums

NOSE Septum, Mucosa, Polyps, Sinuses

MOUTH THROAT

Lesions, Teeth, Tongue, Tonsils

NECK Adenopathy, Thyroid, Vessels, Masses, Voice Abnormalities, lymph nodes

THORAX Shape, Expansion, Deformities

LUNGS Bronchi, Wheezes, Rales

ABDOMEN Organ Enlargement, Masses, Tenderness, Hernia Scars

GENITALIA Lesions, Discharge, Scrotum, Testicles, Hernias

RECTAL Hemorrhoids, Fissures, Prostrate, Masses

EXTREMITIES Pulses, Veins, Edema, Clubbing, Atrophy

NEUROLOGICAL Cranial Nerves, Reflexes, Motor, Gait, Balance Sensory

Athlete Name:__________________ DOB:_____________ Sport:_______________

N=NORMAL AB=ABNORMAL

N AB Comments

SKIN Rash, Ecchymoses, Texture

MENTAL Affect, Hostility, Agitation

HEART PMI Thrills, Sounds, Murmurs, Gallops

Standing exam for heart murmur

Supine exam for heart murmur

Signs of Marfan Syndrome

Exertional chest pain/discomfort

Exertional syncope

Excessive exertional fatigue

Elevated systemic blood pressure or cholesterol

Prior restriction from sport for cardiac concern

Prior cardiac testing my physician

Femoral pulse

FAMILY HISTORY

Premature or sudden death before age 50 due to heart disease

Disability from heart disease before age 50 in close relative

Hypertrophic or dilated cardiomyopathy, long QT syndrome, other ion channelopathies, Marfan syndrome, important arrhythmia

Brachial Blood Pressure Retake (Date)

Pulse Retake (Date)

Athlete Name:__________________ DOB:_____________ Sport:_______________

Physician’s Summary: Needs Further Evaluation Yes No

Cleared For Participation Yes No

Dictation Made Yes No

Physician's Signature Date

____________________________________________________________________________

Name and Address of Physician’s Practice

Physician’s Phone number_____________________________

Physician’s Fax number __________________________