university of alabama at birmingham department of ... · 5/2/2018 · the university of alabama at...

UNIVERSITY OF ALABAMA AT BIRMINGHAM DEPARTMENT OF ATHLETICS – SPORTS MEDICINE

MEDICAL HISTORY QUESTIONNAIRE

Revised 04/18

The information contained in this medical history form will only be used by the Sports Medicine Department of the University of Alabama at Birmingham “UAB”, for purposes of determining if you pose a health threat / risk to yourself on the athletic field. This information will be discussed with you in detail later in your physical examination by a UAB Certified Athletic Trainer and/or Team Physician. This information will remain CONFIDENTIAL at all times.

PERSONAL INFORMATION

Name: ___________________________________________________________ Date: _____________________

Sport: ________________________________ Birth Date: __________________ SSN: _____________________

Age: __________ Sex: __________ Race/Ethnicity: __________ Grade: __________ Scholarship: Yes No

Campus Address: ________________________________ Home Address: ________________________________

City: ________________________________ City: ________________________________

State: ________________________________ State: ________________________________

Zip: ________________________________ Zip: ________________________________

Cell Phone: ________________________________ Home Phone: ________________________________

Blazer ID: ________________________________ Personal Email: ________________________________

Previous Schools Attended: ___________________________________________________________________________

PARENT/GUARDIAN CONTACT INFORMATION

Father’s Name: ________________________________ Mother’s Name: ________________________________

Home Address: same as athlete home address Home Address: same as athlete home address

Street: ________________________________ Street: ________________________________

City: ________________________________ City: ________________________________

State: ________________________________ State: ________________________________

Zip: ________________________________ Zip: ________________________________

Home Phone: ________________________________ Home Phone: ________________________________

Work Phone: ________________________________ Work Phone: ________________________________

Cell Phone: ________________________________ Cell Phone: ________________________________

Email: ________________________________ Email: ________________________________

EMERGENCY CONTACT

Name: ________________________________________________________________ Relation: ____________________

Cell Phone: ________________________________ Home Phone: ________________________________

MEDICAL HISTORY QUESTIONNAIRE 2

Name: ___________________________________________________________ Date: _____________________

Revised 04/18

GENERAL MEDICAL HISTORY

ALLERGIES/ASTHMA

Are you allergic to and/or ever had an unfavorable/allergic reaction to any medications? Yes No

Please Describe _______________________________________________________________________________

Are you allergic to and/or ever had an unfavorable/allergic reaction to any food items? Yes No

Please Describe _______________________________________________________________________________

Are you allergic to and/or ever had an unfavorable/allergic reaction to bee stings, insect bites, etc.? Yes No

Please Describe _______________________________________________________________________________

Have you ever been diagnosed with any allergies? Yes No

Please Describe _______________________________________________________________________________

Are you currently or have you ever taken any medication for allergies (Epi-pen, Benadryl, Claritin, etc.)? Yes No

Please Describe _______________________________________________________________________________

Have you ever been diagnosed with asthma and/or exercise induced asthma? Yes No

Date(s) _____________________________________________________________________________________

Please Describe _______________________________________________________________________________

How many asthma attacks have you had in the past 24 months? ______________________________________________

Are you currently or have you ever taken any medication/inhaler for asthma (Albuterol, Singular, etc.)? Yes No

Please Describe _______________________________________________________________________________

Do you currently see or have you ever seen a pulmonologist and/or allergist? Yes No

Name ___________________________________________ Phone _____________________________________

MEDICATION/SUPPLEMENTS

Are you currently taking any prescription medications? (e.g. anti-depressants, stimulants, ADD, etc.) Yes No

Name of Medication(s) _________________________________________________________________________

Prescribing Physician(s) _________________________________________________________________________

Physician(s) Address/Phone______________________________________________________________________

Are you currently taking any over-the-counter medications? Yes No

Please Describe _______________________________________________________________________________

Have you been told to take a prescription medication which you no longer take? Yes No

Please Describe _______________________________________________________________________________

Are you or have you ever used anabolic steroids or a growth hormone? Yes No

Please Describe _______________________________________________________________________________

Have you ever tested positive for a drug test? Yes No

Please Describe _______________________________________________________________________________

Are you currently taking any supplements? (e.g. Creatine, Vitamins, etc.) see “Nutritional Supplement Disclosure” Yes No

Name _______________________________________________________________________________________

Where ______________________________________________________________________________________

Reason ______________________________________________________________________________________


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

VISION

Do you routinely wear glasses? Yes No

Do you routinely wear contact lenses? Yes No

Type (Hard/Soft/Daily) ___________________________ Brand _____________________________________

Right Sphere __________ Cylinder __________ Axis __________

Left Sphere __________ Cylinder __________ Axis __________

If either of the above apply, who is your eye doctor?

Name ___________________________________________ Phone _____________________________________

When was your last appointment? ____________________

CARDIOVASCULAR

Have you ever had chest pain and/or shortness of breath during or after exercise/practice? Yes No

Please Describe _______________________________________________________________________________

Have you ever felt dizzy, lightheaded, and/or passed out during or after exercise/practice? Yes No

Please Describe _______________________________________________________________________________

Have you ever felt dizzy, lightheaded, and/or passed out for any reason? Yes No

Please Describe _______________________________________________________________________________

Have you ever had the feeling of your heart racing or skipping beats during or after exercise/practice? Yes No

Please Describe _______________________________________________________________________________

Do you get tired more quickly than your teammates/friends during exercise/practice? Yes No

Please Describe _______________________________________________________________________________

Do you frequently cough after exercising? Yes No

Please Describe _______________________________________________________________________________

Have you ever been told you have a heart murmur? Yes No

Please Describe _______________________________________________________________________________

Have you ever been told you have heart disease, hypertrophic cardiomyopathy, Long QT syndrome,

dilated cardiomyopathy, arrhythmia, Marfan’s syndrome or any other related disease? Yes No

Please Describe _______________________________________________________________________________

Does anyone in your family have a history of High Blood Pressure and/or High Cholesterol? Yes No

Please Describe _______________________________________________________________________________

Has any family member or relative died of heart problems and/or of sudden death before age 50? Yes No

Please Describe _______________________________________________________________________________

Have you ever been told that you have High Blood Pressure and/or High Cholesterol? Yes No

Have you ever had an Electrocardiogram (EKG) and/or Echocardiogram “Echo” of your heart? Yes No

Dates(s)/Describe _____________________________________________________________________________

Have you ever seen a Cardiologist for examination? Yes No

Name ___________________________________________ Phone _____________________________________

Has a physician ever denied or restricted your participation in sports due to any heart problems? Yes No


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

HEAT

Have you ever experienced any of the following heat illnesses? Yes No

Heat Cramps Date(s) _________________________________________________

Heat Exhaustion Date(s) _________________________________________________

Heat Stroke Date(s) _________________________________________________

Have you ever received intravenous fluids (IV) for a heat related problem? Yes No

Date(s) ______________________________________________________________________________________

Have you ever been hospitalized for a heat related problem? Yes No

Date(s) __________________________________________ Where? ___________________________________

ENDOCRINOLOGY

Have you ever been diagnosed with diabetes or hypoglycemia? Yes No

Date ________________________________________________________________________________________

Has anyone in your immediate family been diagnosed with diabetes or hypoglycemia? Yes No

Please Describe _______________________________________________________________________________

Have you ever been diagnosed with thyroid problems? Yes No

Date ________________________________________________________________________________________

Has anyone in your immediate family been diagnosed with thyroid problems? Yes No

Please Describe _______________________________________________________________________________

Do you monitor your blood sugar level? Yes No

Please Describe _______________________________________________________________________________

Are you currently taking or have you ever taken any medications for diabetes/thyroid? Yes No

Please Describe _______________________________________________________________________________

GENITOURINARY

MALE:

Are you missing a testicle? Yes No

Have you ever injured or had surgery on your testes? Yes No

FEMALE:

Have you ever been, or are you now pregnant? Yes No

Do you have a history of abnormally heavy bleeding, missed periods or intermittent bleeding? Yes No

At what age were you when periods first occurred? ____________________

How many periods have you had in the past six months? ____________________

How often do you have a menstrual cycle? ____________________

When was your last menstrual cycle? ____________________

What is the usual length of time between periods? ____________________

Are the cycles fairly constant or irregular? ____________________

Have you ever had a pelvic exam? Yes No

Are you currently taking birth control? Yes No

Would you like to discuss any gynecological problems with a physician or staff member? Yes No


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

MENTAL HEALTH

General

Have you ever been diagnosed with mental illness (depression, anxiety, bipolar, ADHD, etc.)? Yes No

Is there a history of mental illness in your family? Yes No

Is there a history of suicide attempts or deaths by suicide in your family? Yes No

Is there a history of alcohol and/or drug use in your family? Yes No

Have you ever experienced a traumatic event or life event? Yes No

(i.e., sexual assault, bullying, loss of life, combat-related trauma, accident)?

Have you every harmed yourself physically in order to relieve emotional pain? Yes No

Have you ever attempted to die by suicide? Yes No

Have you ever been hospitalized for a psychiatric emergency (e.g., suicide ideation)? Yes No

Have you ever been prescribed medications for a mental health related condition? Yes No

Have you ever been under the care of a psychiatrist? Yes No

Have you ever participated in counseling? Yes No

Depression Screening (PHQ-9)

Over the last two weeks, have you been bothered by any of the following problems:

Little interest or pleasure in doing things? Yes No

Feeling down, depressed, or hopeless? Yes No

Trouble falling or staying asleep, or sleeping too much? Yes No

Feeling tired or having little energy? Yes No

Poor appetite or overeating? Yes No

Feeling bad about yourself – or that you are a failure or have let yourself or family down? Yes No

Trouble concentrating on things, such as reading the newspaper or watching television? Yes No

Moving or speaking so slowly that other people could have noticed? Or the opposite –

being so fidgety or restless that you have been moving around a lot more than usual? Yes No

Anxiety Screening (GAD-7)

Over the past two weeks, have you been bothered by the following problems:

Feeling nervous, anxious or on edge? Yes No

Not being able to stop or control worrying? Yes No

Worrying too much about different things? Yes No

Trouble relaxing? Yes No

Being so restless that it is hard to sit still? Yes No

Becoming easily annoyed or irritable? Yes No

Feeling afraid as if something awful might happen? Yes No


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

Eating Disorder Screen (SCOFF)

Do you ever make yourself SICK when you feel uncomfortably full? Yes No

Do you worry you have lost CONTROL over how much you eat? Yes No

Have you recently lost more than 14 pounds within three months? Yes No

Do you believe you are FAT when others say you are too thin? Yes No

Would you say that FOOD dominates your life? Yes No

Substance Use History Screening

Have you ever consumed alcohol to get buzzed or drunk? Yes No

Have you ever used illegal drugs? (including non-prescribed meds, synthetic drugs, marijuana, etc.) Yes No

Have you ever used over-the-counter meds to get buzzed or high? Yes No

Has anyone every told you they are concerned about your use of alcohol and/or other drugs? Yes No

Do you now or have you ever used products containing nicotine? Yes No

Do you drink or take products containing caffeine? Yes No

Have you ever had legal problems as a result of alcohol and/or substance abuse? Yes No

ORTHOPEDIC HISTORY

HEAD

How many years have you played your current sport? ____________

EDUCATION HISTORY

Years of education completed (excluding kindergarten): 12 13 14 Other ______________

Handedness? Right Left Ambidextrous

What is your native language? ___________________

Received speech therapy? Yes No

Attended special education classes? Yes No

Repeated one or more years of school? Yes No

Diagnosed with a learning disability? Yes No

Problems with ADHD or hyperactivity? Yes No

CONTACT SPORT HISTORY

How many years have you played the following sports?

Boxing __________ Field Hockey __________

Football-tackle __________ Ice Hockey __________

Lacrosse __________ Martial Arts __________

Soccer __________ Wrestling __________


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

CONCUSSION HISTORY

Have you ever suffered a head injury/concussion (no matter how minor)? Yes No

Please Describe ______________________________________________________________________________

Date(s) Missed (e.g.practices or games) ___________________________________________________________

Diagnostic Tests? (check all that apply): X-Ray MRI Bone Scan CT Scan Other _____________

Did you see a physician? Yes No Name/Phone _________________________________________

Were you hospitalized? Yes No How long? ___________________________________________

Number of times diagnosed with a concussion: _____________

Dates of each concussion: _____________________________________________________________________________

Number of concussions which resulted in loss of consciousness: _____________

Number of concussions which resulted in confusion: _____________

Number of concussions which resulted in difficulty remembering events after the injury: _____________

Number of concussions which resulted in difficulty remembering events before the injury: _____________

Total games missed as a result of all concussions combined: _____________

TREATMENT HISTORY

Treatment for headaches by a physician? Yes No

Treatment for migraine headaches by a physician? Yes No

Treatment for epilepsy/seizures? Yes No

History of brain surgery? Yes No

History of meningitis? Yes No

Treatment for substance/alcohol abuse? Yes No

Treatment for psychiatric condition? (i.e. depression/anxiety) Yes No

DIAGNOSIS HISTORY

Diagnosed with ADD/ADHD? Yes No

Diagnosed with dyslexia? Yes No

Diagnosed with autism? Yes No

Have you ever been advised not to participate in athletic activities due to a head injury / concussion? Yes No

EAR/NOSE/THROAT

Have you ever suffered an injury to your ear(s), nose, and/or throat? Yes No

Please Describe ______________________________________________________________________________






Name: ___________________________________________________________ Date: _____________________

Revised 04/18

Have you ever had surgery of any kind on your ear/nose/throat? Yes No

When? ____________________ Surgeon Name/Phone ___________________________________________

Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a ear/nose/throat? Yes No

DENTAL

When was your last dental exam? ____________________ Findings? _________________________________________

Do you wear dentures, partials, false teeth, retainers, etc.? Yes No

Please Describe ______________________________________________________________________________

Have you ever suffered an injury to your mouth, jaw, and/or teeth? Yes No

Please Describe ______________________________________________________________________________



Did you see a dentist? Yes No Name/Phone _________________________________________


CERVICAL SPINE/NECK

Have you ever suffered an injury to your cervical spine/neck? Yes No

Date(s) Missed (e.g. practices or games) ___________________________________________________________




Have you ever had “burners/stingers” or any Brachial Plexus Injury? Yes No

How many? __________ Please Describe ____________________________________________________

Have you ever experienced numbness and/or tingling in your arms/fingers? Yes No

One side Both sides Please Describe ____________________________________________________

Have you ever or do you currently wear a neck roll/collar, Cowboy/Kerr Collar, Butterfly plate, etc.? Yes No

Please Describe ______________________________________________________________________________

Have you ever seen a chiropractor and/or massage therapist for your cervical spine/neck? Yes No

Have you ever had surgery of any kind on cervical spine/neck? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to cervical spine/neck injury? Yes No

Have you ever been advised not to participate in athletic activities due to cervical spine/neck pain? Yes No

SHOULDER/UPPER ARM

Have you ever suffered an injury to your shoulder/upper arm? Yes No

Please Describe ______________________________________________________________________________

How did you injure (e.g. throwing, contact, etc.)? ___________________________________________________



Name: ___________________________________________________________ Date: _____________________

Revised 04/18



Were you hospitalized? Yes No How long? __________________________________________

Has your shoulder ever “come out of place”/dislocated or felt like it has? Yes No

Do you ever have pain/discomfort in your shoulder at night? Yes No

Have you ever had surgery of any kind on your shoulder/upper arm? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a shoulder/upper arm injury? Yes No

ELBOW/FOREARM

Have you ever suffered an injury to your elbow/forearm? Yes No

Please Describe ______________________________________________________________________________






Have you ever had your elbow/forearm in a cast or immobilized? Yes No

Have you ever had a calcium deposit form in your arm following a bad muscle strain or bruise? Yes No

Please Describe ______________________________________________________________________________

Have you ever had surgery of any kind on your elbow/forearm? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to an elbow/forearm injury? Yes No

WRIST/HAND/FINGERS

Have you ever suffered an injury to your wrist(s), hand(s), and/or finger(s)? Yes No

Please Describe ______________________________________________________________________________


Date(s) Missed (e.g. practices or games) ___________________________________________________________




Have you ever had your wrist(s), hand(s), and/or finger(s) in a cast or immobilized? Yes No

Have you ever had surgery of any kind on your wrist(s), hand(s), and/or finger(s)? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a wrist/hand/finger injury? Yes No


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

SPINE/LOW BACK/ SACROILIAC (S-I) JOINT

Have you ever suffered an injury to your spine/low back/S-I joint? Yes No

Please Describe ______________________________________________________________________________

How did you injure? ____________________________________________________





Have you ever been told you have a congenital spine defect? Yes No

Please Describe ______________________________________________________________________________

Have you ever been told you have spondylolisthesis/spondylolysis or “Spondy”? Yes No

Please Describe ______________________________________________________________________________

Have you ever had numbness/tingling down one or both legs? Yes No

One side Both sides Please Describe __________________________________________________

Have you ever had a back muscle strain? Yes No

Low Back High Back Please Describe __________________________________________________

Do you have frequent back aches? Yes No

Please Describe ______________________________________________________________________________

Have you ever had surgery of any kind on your spine/low back/S-I joint? Yes No


Please Describe ______________________________________________________________________________

Have you ever seen a Chiropractor and/or Massage Therapist for treatment? Yes No

Have you ever been advised not to participate in athletic activities due to a spine/back/S-I injury? Yes No

RIBS/THORAX/CHEST

Have you ever suffered an injury to your rib(s), thorax, and/or chest? Yes No

Please Describe ______________________________________________________________________________





Have you ever had surgery of any kind on your rib(s), thorax, and/or chest? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a rib/thorax/chest injury? Yes No

ABDOMEN

Have you ever suffered an injury to your abdomen? Yes No

Please Describe ______________________________________________________________________________




Name: ___________________________________________________________ Date: _____________________

Revised 04/18



Do you routinely suffer from severe or recurrent abdominal pain? Yes No

Do you routinely suffer from chronic or recurrent diarrhea? Yes No

Do you have only one of two paired organs (kidney, testicles, ovary, etc.)? Yes No

Have you ever had surgery of any kind on your abdomen? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to an abdomen injury? Yes No

HIP/GROIN

Have you ever suffered an injury to your hip(s) and/or groin? Yes No

Please Describe ______________________________________________________________________________





Have you ever had surgery of any kind on your hip(s) and/or groin? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a hip/groin injury? Yes No

THIGH

Have you ever suffered an injury to your thigh, hamstrings and/or quadriceps? Yes No

Please Describe ______________________________________________________________________________





Have you ever had surgery of any kind on your thigh, hamstrings and/or quadriceps? Yes No


Please Describe ______________________________________________________________________________

Have you ever had a calcium deposit form in your thigh following a bad muscle strain or bruise? Yes No

Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a thigh injury? Yes No

KNEE

Have you ever suffered an injury to your knee? Yes No

Please Describe ______________________________________________________________________________

How did you injure? ___________________________________________________________________________



Name: ___________________________________________________________ Date: _____________________

Revised 04/18




Have you ever/do you presently wear a knee brace? Yes No

Which knee(s)? _________________________ Brand/Model of brace? _________________________________

Have you ever had your knee(s) in a cast or immobilized? Yes No

Does your knee ever collect fluid or swell during or after activity? Yes No

Please Describe ______________________________________________________________________________

Does your knee lock, give way, and/or feel unstable during or after activity? Yes No

Please Describe ______________________________________________________________________________

Have you ever had surgery of any kind on you knee(s)? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a knee injury? Yes No

ANKLE

Have you ever suffered an injury to your ankle? Yes No

Please Describe ______________________________________________________________________________

How did you injure? ___________________________________________________________________________





Have you ever had your ankle(s) in a cast or immobilized in a boot? Yes No

Have you had several ankle sprains in the past? Yes No

Please Describe ______________________________________________________________________________

Have you ever had surgery of any kind on your ankle(s)? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to an ankle injury? Yes No

Do you wear braces or get taped for games and practices? Yes No

Tape Brace

FOOT/TOES

Have you ever suffered an injury to your feet and/or toes? Yes No

Please Describe ______________________________________________________________________________






Name: ___________________________________________________________ Date: _____________________

Revised 04/18

Have you ever had shin splints? Yes No

Have you ever been told you have flat feet or high arches? Yes No

Have you ever had “turf toe”? Yes No

Have you ever or do you currently wear orthotics? Yes No

Have you ever had surgery of any kind on your feet and/or toes? Yes No


Please Describe ______________________________________________________________________________

Have you ever been advised not to participate in athletic activities due to a foot/toes injury? Yes No

SUPPLEMENTAL REVIEW

Do you have any medical problems not mentioned in the above sections? Yes No

Please Describe ______________________________________________________________________________

Did you miss any games/practices because of injury/illness at your high school or previous college? Yes No

Please Describe ______________________________________________________________________________

Have you ever dislocated any joint? Yes No

Please Describe ______________________________________________________________________________

Have you ever had any fractured (broken) bones? Yes No

Please Describe ______________________________________________________________________________

Have you ever had a bad muscle “pull” or strain? Yes No

Please Describe ______________________________________________________________________________

Do you require any special equipment/taping/bracing for any of the above mentioned problems? Yes No

Please Describe ______________________________________________________________________________

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

Please Describe ______________________________________________________________________________

Have you ever been involved in a Motor Vehicle Accident which required medical attention? Yes No

Please Describe ______________________________________________________________________________

Have you ever been diagnosed with a Communicable Disease (STD, HIV, Hepatitis, TB, etc.)? Yes No

Please Describe ______________________________________________________________________________


Name: ___________________________________________________________ Date: _____________________

Revised 04/18

SICKLE CELL AUTHORIZATION

The University of Alabama at Birmingham and Conference USA require proof of Hemoglobin Type Testing for

identification of certain blood disorders, particularly Sickle Cell Trait and Sickle Cell Anemia. A result of either

“NEGATIVE” or “POSITIVE” must be clearly indicated on form.

In an effort to avoid delay in being declared eligible for participation, UAB requests that all student-athletes be tested

for sickle cell prior to arriving on campus or provide documentation from birth records which state sickle cell status. If

the Athletic Training Department does not receive the student-athlete’s sickle cell testing results prior to his/her arrival,

testing will be arranged for him/her by a member of the UAB Athletic Training Staff, but the student-athlete will not be

able to participate until results of the test are available.

I, the undersigned, grant UAB permission to administer the aforementioned test and/or refer to a contracted testing agency.

Date: __________

Name: ____________________________________ Signature: ________________________________________

** If under the age of 19, Parent Signature is required ** Signature: ________________________________________

I have provided, or will provide, a copy of previous testing results

Results may be sent to: UAB Sports Medicine; 608 13th Street S – WB104, Birmingham, AL 35294 -or- fax (205)975-9258

STATEMENT

I, the undersigned, hereby state that to the best of my knowledge, all of the information in this questionnaire is correct and accurate. I understand that my failure to report medical history accurately could result in a delay of my clearance for athletic participation.

Date: __________ Name: _________________________________________ Signature: __________________________________________

** If under the age of 19, Parent Signature is required ** Signature: __________________________________________

REVIEW

This packet was reviewed by:

Date: __________

Name: _____________________________________ ATC Signature: __________________________________________

Date: __________

Name: _____________________________________ MD Signature: __________________________________________


INSURANCE INFORMATION

DEMOGRAPHICS

Name: ____________________________________________________________ Date: _____________________

Sport: ________________________________ Birth Date: __________________ SSN: _____________________

Home Address: _____________________________________________________ Phone: _____________________

Campus Address: ____________________________________________________ Phone: _____________________


Please fill out ALL information below and give copy of ALL active medical, dental, and prescription cards

to the team athletic trainer.

The Student-Athlete is not covered under any personal health/vision/dental insurance. (ALL WALK-ON STUDENT-ATHLETES ARE REQUIRED TO HAVE PERSONAL HEALTH INSURANCE)

PRIMARY INSURANCE SECONDARY INSURANCE Ins. Company Name: Ins. Company Name:

Policy #: Group #: Policy #: Group #:

Is preauthorization necessary for medical/diagnostic services? Yes No


Policyholder: Relationship: Policy Holder: Relationship:

Date of Birth: SS No. Date of Birth: SS No.

Home Address: Home address:

City: State: Zip: City: State: Zip:

Home Phone: Cell Phone: Home Phone: Cell Phone:

Employer: Employer:

DENTAL INSURANCE PRESCRIPTION INSURANCE

Ins. Company Name: Ins. Company Name:

Policy #: Group #: Policy #: Group #:


Bin #:

Policyholder: Relationship: Policy Holder: Relationship:

Date of Birth: SS No.: Date of Birth: SS No.:

Home Address: Home Address:

City: State: Zip: City: State: Zip:

Home Phone: Cell Phone: Home Phone: Cell Phone:

Employer: Employer:

PRIMARY CARE PHYSICIAN

Primary Care Physician: Physician Phone #:


Revised 05/16

ACKNOWLEDGEMENT

I certify that all of the information provided on the previous page is correct and that if any incorrect information has been given, then I am responsible for the payment of charges. S-A Initials __________ I authorize the UAB Athletic Department to file claim in my behalf for all claims classified as “Athletic”. I understand that I am responsible for payments of all charges incurred for claims classified as “Non-Athletics” or “Pre-Existing” injury/illness. S-A Initials __________

AUTHORIZATION (For student-athletes with personal health insurance)

THE FOLLOWING AUTHORIZATION MUST BE SIGNED BEFORE UAB CAN COVER ANY MEDICAL EXPENSE INCURRED BY THIS ATHLETE:

The Student-Athlete is not covered under any personal health/vision/dental insurance (go to next section).

The UAB Athletic Department is authorized to file a claim on my behalf for any “Athletic” injury/illness sustained by ______________________________ (student-athlete name) under the above insurance policy. Further, I agree and

consent that any amounts payable under this policy be paid to the medical provider or UAB Athletic Department as shown below.

I, the undersigned, do hereby agree and give my consent for the UAB Athletic Department or its designates to furnish medical care and treatment to my son/daughter as considered necessary and proper in diagnosing or treating their physical and mental conditions. Further, I hereby authorize UAB Athletic Department and its representatives to inspect or secure copies of case history, laboratory reports, diagnosis, x-rays, and any other data in relation to this medical claim. This authorization may be photocopied and any photocopies should be deemed as valid and applicable to the original. Signature of Policy Holder: __________________________________________ Date: ____________________ Student-Athlete Signature: __________________________________________ Date: ____________________

CATASTROPHIC INSURANCE

As an insured intercollegiate student-athlete, enrolled at the University of Alabama at Birmingham (UAB), the UAB Athletic Department is pleased to provide you with Catastrophic Injury coverage. Under this coverage, as an insured student-athlete, you are provided with accident death and dismemberment benefits while participating in intercollegiate athletics at UAB. 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 to. This beneficiary(ies) designation may be changed by you at any time. I, the undersigned, acknowledge and understand that if I do not name a beneficiary or if my named beneficiary does not survive me, that the payment of 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) any surviving siblings, equally.

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

Name: _______________________________________ Relation: _______________________________

Name: _______________________________________ Relation: _______________________________ Date: __________

Name: _________________________________________ Signature: __________________________________________



Revised 05/16

CARD COPIES

Please provide a legible copy, FRONT and BACK, of your primary insurance card and the policy holder’s driver license or identification card. Please also provide any copies of any prescription, dental, vision, and/or secondary insurance cards, if applicable.

PRIMARY

Front Back

ID

SECONDARY/VISION/DENTAL/PRESCRIPTION (attach separate sheet if needed)

UNIVERSITY OF ALABAMA AT BIRMINGHAM ATHLETIC DEPARTMENT – SPORTS MEDICINE

DISCLOSURE OF PROTECTED HEALTH INFORMATION FROM UAB

Revised 08/16

DEMOGRAPHICS

Patient Name: _________________________________ Patient Birthdate: _____________________________________

Patient SSN: __________-_________-______________ Patients Address: _____________________________________

Patients Phone: (_________) _____________________ City, State, Zip: _______________________________________

AUTHORIZED INFORMATION

This authorization applies to the following information:

All Information - This includes any information relating to drug and/or alcohol abuse/treatment, communications with psychiatrists or psychologist, genetic

testing, or records pertaining to sexually transmitted diseases, if they are part of my medical record.

Only the Following Record or Types of Information: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

STATEMENT

I hereby authorize/consent to the release of my protected health information and any related medical information regarding any injury, illness, or treatment by my health care provider(s) by the coaches, athletic trainers, sports medicine staff and other Health care personnel, including physicians representing the University of Alabama at Birmingham Athletic Department, to other health care providers, my parents/guardians, hospitals and/or medical clinics and laboratories, athletics coaches, strength and conditioning coaches, medical insurance coordinators, insurance carriers, medical supply vendors and/or services companies, academic counselors, athletic and/or university administrators, chaplains and/or clergy members, NCAA Injury Surveillance System, scouts, sports information staff and members of the media for any educational or medically related purposes (e.g., treatment, payment, health care operations, etc.).

I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete for the University of Alabama at Birmingham. I understand that my protected health information is protected by federal regulations under either the Health Insurance Portability and Accountability Act (“HIPAA”) or the Family Educational Rights and Privacy Act of 1974 (“FERPA” or the “Buckley Amendment”) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment.

I understand that I may revoke this authorization/consent at any time by notifying, in writing, a member of the Athletic Training staff, but if I do, it will not have any effect on actions the University of Alabama at Birmingham or the University of Alabama at Birmingham Athletic Department took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires six (6) years from the date it is signed.

Student-Athlete Signature: __________________________________________ Date: _____________________


Witness Signature: __________________________________________ Date: _____________________

UNIVERSITY OF ALABAMA AT BIRMINGHAM ATHLETIC DEPARTMENT – SPORTS MEDICINE

DISCLOSURE OF PROTECTED HEALTH INFORMATION TO UAB

Revised 04/18

DEMOGRAPHICS

Patient Name: _________________________________ Patient Birthdate: _____________________________________

Patient SSN: __________-_________-______________ Patients Address: _____________________________________

Patients Phone: (_________) _____________________ City, State, Zip: _______________________________________

AUTHORIZED INFORMATION

This authorization applies to the following information:

All Information - This includes any information relating to drug and/or alcohol abuse/treatment, communications with psychiatrists or psychologist, genetic

testing, or records pertaining to sexually transmitted diseases, if they are part of my medical record.

Only the Following Record or Types of Information: ___________________________________________________________________________ ___________________________________________________________________________ The Information May Be Released As Follows:

From: All Universities, Colleges, High Schools, Physicians, Athletic Trainers, Hospitals, Clinics, Pharmacies, and Treatment Facilities.

To: University of Alabama at Birmingham University of Alabama at Birmingham Athletic Training Department Football Athletic Training Room 608 13th Street South – WB 104 1219 6th Ave South Birmingham, Alabama 35294 Birmingham, Alabama 35294 P: (205)934-6013 F: (205)975-9258 P: (205)975-9256 F: (205)975-7228

STATEMENT

I hereby authorize/consent to the release of my protected health information and any related medical information regarding any injury, illness, or treatment by my health care provider(s) to the coaches, athletic trainers, sports medicine staff and other health care personnel, including physicians representing the University of Alabama at Birmingham Athletic Department for my qualification, training or participation in intercollegiate athletics. Protected health information includes my medical status, medical condition, injuries, prognosis, or diagnosis.

I understand that my authorization/consent for the disclosure of my protected health information is a condition for participation as an intercollegiate athlete for the University of Alabama at Birmingham. I understand that my protected health information is protected by federal regulations under either the Health Insurance Portability and Accountability Act (“HIPAA”) and/or the Family Educational Rights and Privacy Act of 1974 (“FERPA” or the “Buckley Amendment”) and may not be disclosed without either my authorization under HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per my authorization/consent, the information is subject to re-disclosure and may no longer be protected by HIPAA and/or the Buckley Amendment.

I understand that I may revoke this authorization/consent at any time by notifying, in writing, a member of the University of Alabama at Birmingham athletic training staff, but if I do, it will not have any effect on actions the University of Alabama at Birmingham or the University of Alabama at Birmingham Athletic Department took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires six (6) years from the date it is signed.

Student-Athlete Signature: __________________________________________ Date: _____________________


Witness Signature: __________________________________________ Date: _____________________


ASSUMPTION OF RISK, VOLUNTARY WAIVERS, RELEASE OF LIABILITY AND INFORMED CONSENT

Revised 08/16

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING IT. THIS IS A LEGALLY BINDING AGREEMENT BETWEEN THE STUDENT ATHLETE IDENTIFIED BELOW AND THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ALABAMA FOR THE UNIVERSITY OF ALABAMA AT BIRMINGHAM (UAB).

INFORMED CONSENT AND ASSUMPTION OF RISK

Many athletic activities involve substantial risks of bodily injury, property damage, and other dangers associated with participation. I acknowledge that participation in athletics involves risks of injury incidental thereto including, without limitation, physical contact with other participants, bystanders, the playing surface, training equipment and other objects in and around the field of play. I understand that the dangers of such activities include, but are not limited to: death, hypothermia, broken bones, strains, sprains, bruises, drowning, concussion, heart attack, and heat exhaustion, and that each participant in such activities should realize that there are risks, hazards, and dangers inherent in such activities and in the training, preparation for, and travel to and from such activities. I understand that such injuries may result in significant impairment of my future ability to earn a living, to engage in social and recreational activities, to produce a family, and to enjoy life. I acknowledge that such injuries can be serious or severe, could last my entire life and could result in economic and property loss. I also acknowledge that there may be other dangers, hazards or risks that are not presently known or reasonably foreseeable.

I also understand that protective equipment cannot prevent or minimize all risk of injury or death. Even if the protective equipment is well designed and maintained, it cannot ensure that I will not sustain head, neck or other serious injuries while engaging in athletic activities. I understand and agree that I am responsible for the safety and good operating condition of all equipment that I may use, regardless of its source, that I am not to alter or modify any protective equipment without prior approval, and that I will read and comply with all warnings provided with any protective equipment. I understand the risk of injury from using poorly fitted, worn or defective protective equipment and from the use or misuse of protective equipment to deliberately injure an opponent player. I understand and agree to follow the safety precautions required for participation.

I acknowledge the importance of following and agree to follow all rules and regulations pertaining to the sport in which I participate. I further understand that despite complying with these rules and the instructions regarding my protective equipment, there is nevertheless a significant risk of injury inherent in athletics activities.

I voluntarily accept and assume all risks, physically, emotionally, financially and legally, including without limitation, risks of injury, loss of life or damage to property arising out of athletics-related activities.

RELEASE OF LIABILITY, VOLUNTARY WAIVER OF CLAIMS AND INDEMNITY

The undersigned hereby agrees that in return for the consideration of UAB allowing the undersigned to participate in athletic activities or making available any equipment, facilities, grounds, or personnel for such activities, the undersigned does hereby release and forever discharge UAB and its trustees, officers, agents and employees (the “UAB Indemnities”) of any and all claims, demands, rights, and causes of action of whatever kind or nature, arising from any injuries, damage to property, and the consequences thereof, including death or serious injury, resulting from my participation in any way connected with such athletic activities. I further agree to indemnify and defend the UAB Indemnities from and against and all liability, causes of action, claims and demands of every kind whatsoever that may or does arise out of my participation in my athletic activity. The terms hereof shall be binding on my heirs, estate, executor, administrator, assignees, and all members of my family.

CHOICE OF LAW

This Agreement shall be governed by and construed under the laws of the State of Alabama. I agree that any legal action relating to this Agreement, or arising out of any injury, death, damage or loss as a result of my participation in these athletic activities shall be brought in The Board of Adjustment for The State of Alabama. Exclusive jurisdiction and venue of any claims that are not required to be filed before the Alabama State Board of Adjustment shall lie exclusively in the federal and State courts sitting in Jefferson County, Alabama.

Date: __________

Name: _________________________________________ Signature: __________________________________________


WAIVERS AND CONSENT

Revised 12/16

MEDICAL CONSENT AND REPORTING OF INJURIES

I agree to take responsibility for reporting injuries and illness in a timely manner to the UAB Athletics Sports Medicine Department staff.

I, the undersigned, hereby grant permission to the UAB team physicians and/or any consulting physicians or other allied health professionals to render any treatment, medical, and/or surgical care that is deemed necessary for the health and well-being of the undersigned student-athlete, which may occur, while participating in intercollegiate athletics for UAB.

I also hereby authorize the athletic trainers at UAB, who are under the direction and guidance of the UAB team physicians, to render any preventative, first-aid, rehabilitation, or emergency treatment deemed reasonably necessary for the health and well-being of the undersigned student-athlete. Also, when necessary for executing such care, I grant permission for transport and hospitalization at an accredited hospital. I further understand that the team physician and/or his/her designee have the authority to eliminate me from participation as a student-athlete in order to protect my health, safety and well-being, to protect the health, safety or well-being of another, due to an injury/illness, and/or due to undue liability risk for UAB.

Date: __________

Name: _________________________________________ Signature: __________________________________________


MEDICAL EXPENSES

Per NCAA Bylaw 16.4, “An institution, conference or the NCAA may provide medical and related expenses and services to a student-athlete.” Such expenses include, but are not necessarily limited to: athletics medical insurance, medical examinations, medical treatments, medication, physical therapy, chiropractic, massage therapy, drug rehabilitation expenses, counseling services, and vision expenses incurred during the season.

All injuries/illnesses should be reported to the UAB athletic trainers and team physicians (collectively referred to herein as the “UAB Athletics Sports Medicine Department”). They will provide medical care as deemed appropriate for the reported illness or injury.

The Athletics Department provides excess medical insurance for injuries sustained while participating in a university-sponsored intercollegiate activity. The Athletics Department’s coverage is “in-excess” to any personal, primary medical insurance (typically provided through parent(s) or purchased by or for the individual student-athlete) and the university provided coverage does not come into effect until payment is processed/filed through any primary coverage. Each student-athlete is required to provide current insurance information. For student-athletes who do not have personal medical insurance, it is recommended they purchase primary insurance coverage through the school: https://www.uab.edu/studenthealth/insurance-and-waivers/optional-insurance

Second Opinions: Student-athletes should consult with the team physician before seeking a second opinion from a specialist. If a student-athlete seeks the services of another specialist without consultation and referral by the team physician and the Associate Athletic Director of Sports Medicine, the Athletics Department will not be financially responsible for the expense to obtain the opinion or for subsequent treatment not approved as required. Regardless of approved/non-approved second opinion, the student-athlete must report back to the UAB Athletics Sports Medicine Department following examination by an outside specialist (all records, reports, images, etc.) The UAB team physician has final authorization on clearance and participation.

Corrective contact lenses or glasses required by a student athlete for general use will not be paid for by the Athletics Department. Athletes requiring vision correction specifically for athletic participation may be eligible for up to a 6-month supply. Replacement contact lenses beyond what may be supplied by the UAB Athletics Sports Medicine Department are the student-athlete’s financial responsibility.

Dental injuries incurred by a student-athlete while participating in an organized practice or intercollegiate competition will be covered under the Athletics Department Insurance Policy Procedures. Any charges related to filling cavities, annual checkups, or routine dental work will not be covered by the Athletics Department.

I, the undersigned, acknowledge and understand that while permissible according to the NCAA; all medical and related expenses incurred while a student-athlete at UAB are subject to institutional approval. The Associate Athletic Director for Sports Medicine is designated with the authority to approve and/or deny any such expenses.

Date: __________

Name: ____________________________________ Signature: __________________________________________


https://www.uab.edu/studenthealth/insurance-and-waivers/optional-insurance

https://www.uab.edu/studenthealth/insurance-and-waivers/optional-insurance

WAIVERS AND CONSENT

Revised 12/16

DRUG AND ALCOHOL EDUCATION AND TESTING

I, the undersigned, agree to participate in a substance use/abuse testing program as required under the UAB Department of Athletics, Drug and Alcohol Education and Testing Program. This program includes 1) Oral Swab, 2) Witnessed Urine Sample, 3) Blood Sample, 4) Hair Sample, or any other valid testing measure determined per the policy for sample collection. Separate, but in accordance with the NCAA Banned substance, this program is designed for the education, detection, and treatment of any substance use/abuse during the student-athlete’s participation in intercollegiate athletics at UAB. Such substances include any illicit and/or performance enhancing drugs, alcohol, tobacco, nutritional supplements, and/or misuse of Legally Obtained Medications.

I hereby waive any applicable provisions of the Family Education Rights and Privacy Act for participation in this program, only to the extent as may be herein provided, and consent to the disclosure of the results of the tests undergone as required for purposes of the Treatment/Disciplinary Plan, outlined in the Department of Athletics Drug and Alcohol Education and Testing Program. No further waiver or consent is contemplated hereby, and access to the results by others will be resisted to the fullest extent permitted by law.

I hereby release fully UAB and the UAB Indemnitees from any liability for the release of the results of the substance abuse tests outlined above and as consented to herein.

I HAVE RECEIVED AND UNDERSTAND THE POLICIES OF THE UAB DEPARTMENT OF ATHLETICS DRUG AND ALCOHOL EDUCATION AND TESTING PROGRAM. I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS AND/OR HAVE THE POLICY EXPLAINED TO ME. I UNDERSTAND THAT NOT FOLLOWING THIS POLICY MAY LEAD TO SUSPENSION OR PERMANENT DISMISSAL FROM THE TEAM.

Date: __________

Name: _________________________________________ Signature: __________________________________________


NUTRITIONAL SUPPLEMENT DISCLOSURE

Since the interpretation of NCAA Bylaw 16.5.2.2 (“It is not permissible for an institution to provide a nutritional supplement to its student-athletes, unless the supplement is a nonmuscle-building supplement …”) student-athletes have been obtaining supplements from sources other than UAB. As a student-athlete you must know that supplements are not regulated by any state or federal agency, therefore the ingredient list may not be complete or correct. There is a risk that the supplement may have NCAA banned substances. If you test positive in an NCAA urine screen, you could lose up to 1 year of eligibility.

In an effort to decrease the chance of a positive test, the Athletics Department is requiring that you complete this disclosure. If you are not taking ANY supplements, state that, if you are taking supplements, list them below. It is your responsibility to bring the supplement ingredient list to the UAB Athletics Sports Medicine Department staff for their review. If you change supplements or start a new supplement, have the ingredient list reviewed by the UAB Athletics Sports Medicine Department staff.

I, the undersigned, understand it is my responsibility to insure that I am not taking an NCAA banned substance and:

I am NOT taking any supplements at this time. If I start, I will review the supplement with the UAB Athletics Sports Medicine Department staff.

I am taking the following supplement(s):

NAME WHERE PURCHASED REASON

WAIVERS AND CONSENT

Revised 12/16

PRESCRIPTION MEDICATIONS & NCAA MEDICAL EXCEPTIONS

The NCAA bans performance enhancing drugs to protect student-athlete health and safety and to ensure a level playing field (Bylaw 31.2.3.4). However, the NCAA recognizes that some banned substances are used for legitimate medical purposes, and will grant exceptions from a positive drug test for those student-athletes who are able to provide medical records which demonstrate that they have a medical need and current prescription for a banned substance. Exceptions may be granted for the following drug classes: stimulants used to treat ADD/ADHD, beta-2 agonists, diuretics and masking agents, anti-estrogens, peptide hormones and analogues*, and anabolic agents (steroids)*. (Bylaw 31.2.3.5) [*anabolic agents and peptide hormones must be approved by the NCAA before the athlete is allowed to participate while taking these medications. The institution, through its Director of Athletics and/or designee, may request an exception for use of an anabolic agent or peptide hormone by submitting to The National Center for Drug Free Sport any medical documentation it wishes to have considered.]

Student-athletes are responsible for notifying the UAB Athletics Sports Medicine Department staff that they are taking prescription medication for which they may require a medical exception. In order for a student-athlete to be granted a medical exception for the use of a medication that contains a banned substance, the student-athlete must:

1. Declare the use of the substance to the Associate Athletic Director for Sports Medicine and/or his designee responsible for keeping medical records

2. Present documentation of the diagnosis of the condition 3. Provide documentation from the prescribing physician explaining the course of treatment

and the current prescription including dosage amount

Requests for medical exceptions will be reviewed by physicians who are members of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports.

NOTE TO STUDENTS DIAGNOSED WITH ADD/ADHD:

The NCAA has indicated a stricter application of the NCAA Medical Exception Policy as it applies to banned stimulant medications used to treat ADD/ADHD. If the student athlete does not undergo a standard assessment to diagnose ADD/ADHD, they have not met the requirements for an NCAA medical exception. The student-athlete should provide documentation of an earlier assessment, or undergo an assessment prior to using stimulant medication for ADD/ADHD. The stricter application will require the following:

1. Documentation the student-athlete has undergone a clinical assessment to diagnose ADD/ADHD

2. Student-athlete is being monitored regularly for use of the stimulant medication

3. Non-banned medications/alternatives have been considered prior to use of banned substance

4. Current prescription on file

I, the undersigned, understand that as a student-athlete I must submit all medical documentation pertaining to any prescription medication I am currently taking or have taken within the past 12 months. I further accept that if I choose to seek medical consultation outside of the authorization of the UAB Athletics Sports Medicine Department staff, it is my responsibility to inform the Associate Athletic Director for Sports Medicine and/or his/her designee about any medications which may have been prescribed to me. In addition, I understand that I must present this information to the Associate Athletic Director for Sports Medicine and/or his/her designee within 2 days of the medication being prescribed. I further understand that should I test positive for a banned substance, I will be in violation of the NCAA and UAB’s Substance Abuse Policies if appropriate medical documentation has not been presented to the Associate Athletic Director for Sports Medicine and/or his/her designee and the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports.

Date: __________

Name: _________________________________________ Signature: __________________________________________


WAIVERS AND CONSENT

Revised 12/16

CONCUSSION WAIVER

What is a CONCUSSION? A concussion is a brain injury caused by a blow to the head, face or elsewhere on the body with a force transmitted to the head. Concussions can result from hitting a hard surface such as the ground or floor, from players colliding with each other or from being hit by a ball, bat or other sporting equipment.

Facts about CONCUSSION 1. A concussion is a serious brain injury

2. Concussions can occur without loss of consciousness or other obvious signs

3. Concussions can occur from blows to the body as well as to the head

4. Concussions can occur in any sport

5. Athletes can still get a concussion even if they are wearing a helmet

6. Recognition and proper response to concussions when they first occur can help prevent further injury or even death

Signs and Symptoms of CONCUSSION include 1. Headache or “pressure” in head

2. Nausea or vomiting

3. Balance problems or dizziness

4. Double or blurry vision

5. Sensitivity to light and /or noise

6. Feeling sluggish, hazy, foggy or groggy

7. Concentration or memory problems

8. Confusion

9. Sensation that one does not “feel right”

Why knowing you have a CONCUSSION is important Most concussions resolve but some concussions can lead to chronic symptoms such as headache, decreased memory, sleeping problems or personality change. Rest, avoiding another blow to the head and following the advice of your medical staff are critical in helping you recover as fast and as safely as possible. Sustaining another concussion prior to recovery from the first increases your chance of long-term symptoms. There have been reports of death with a second concussion in younger athletes. It is very important for you to report any concussion symptoms as described above to your UAB Athletics Sports Medicine Department staff at the time of injury. This includes alerting the UAB Athletics Sports Medicine Department staff to symptoms in your teammates if you notice these.

I, the undersigned, accept responsibility for reporting all injuries and illnesses to the UAB Athletics Sports Medicine Department including any signs and symptoms of CONCUSSION. I have read and understand the above information on concussion and the NCAA’s “Concussion Safety: What Student-Athletes Need to Know”. I will inform the UAB Athletics Sports Medicine Department staff immediately if I experience any of these symptoms or witness a teammate with these symptoms.

Date: __________

Name: _________________________________________ Signature: __________________________________________


How can I keep myself safe?1. Know the symptoms. You may experience …

• Headache or head pressure• Nausea• Balance problems or dizziness• Double or blurry vision• Sensitivity to light or noise• Feeling sluggish, hazy or foggy• Confusion, concentration or memory problems 2. Speak up.

• If you think you have a concussion, stop playing and talk to your coach, athletic trainer or team physician immediately.

3. Take time to recover.• Follow your team physician and athletic trainer’s

directions during concussion recovery. If left unmanaged, there may be serious consequences.

• Once you’ve recovered from a concussion, talk with your physician about the risks and benefits of continuing to participate in your sport.

How can I be a good teammate?1. Know the symptoms.You may notice that a teammate …

• Appears dazed or stunned• Forgets an instruction• Is confused about an assignment or position• Is unsure of the game, score or opponent• Appears less coordinated• Answers questions slowly• Loses consciousness

2. Encourage teammates to be safe.

• If you think one of your teammates has a concussion, tell your coach, athletic trainer or team physician immediately.

• Help create a culture of safety by encouraging your teammates to report any concussion symptoms.

3. Support your injured teammates.

• If one of your teammates has a concussion, let him or her know you and the team support playing it safe and following medical advice during recovery.

• Being unable to practice or join team activities can be isolating. Make sure your teammates know they’re not alone.

What is a concussion?A concussion is a type of traumatic brain injury. It follows a force to the head or body and leads to a change in brain function. It is not typically accompanied by loss of consciousness.

No two concussions are the same. New symptoms can appear hours or days after the initial impact. If you are unsure if you have a concussion, talk to your athletic trainer or team physician immediately.

CONCUSSION SAFETY

WHAT STUDENT-ATHLETES NEED TO KNOW

What happens if I get a concussion and keep practicing or competing?

• Due to brain vulnerability after a concussion, an athlete may be more likely to suffer another concussion while symptomatic from the first one.

• In rare cases, repeat head trauma can result in brain swelling, permanent brain damage or even death.

• Continuing to play after a concussion increases the chance of sustaining other injuries too, not just concussion.

• Athletes with concussion have reduced concentration and slowed reaction time. This means that you won’t be performing at your best.

• Athletes who delay reporting concussion take longer to recover fully.

What are the long-term effects of a concussion?

• We don’t fully understand the long-term effects of a concussion, but ongoing studies raise concerns.

• Athletes who have had multiple concussions may have an increased risk of degenerative brain disease and cognitive and emotional difficulties later in life.

NCAA | SPORT SCIENCE INSTITUTE | CONCUSSION SAFETY | WHAT STUDENT–ATHLETES NEED TO KNOW

For more information, visit ncaa.org/concussion.NCAA is a trademark of the National Collegiate Athletic Association.

What do I need to know about repetitive head impacts?

• Repetitive head impacts mean that an individual has been exposed to repeated impact forces to the head. These forces may or may not meet the threshold of a concussion.

• Research is ongoing but emerging data suggest that repetitive head impact also may be harmful and place a student-athlete at an increased risk of neurological complications later in life.

Did you know?

• NCAA rules require that team physicians and athletic trainers manage your concussion and injury recovery independent of coaching staff, or other non-medical, influence.

• We’re learning more about concussion every day. To find out more about the largest concussion study ever conducted, which is being led by the NCAA and U.S. Department of Defense, visit ncaa.org/concussion.

CONCUSSION TIMELINE

Baseline TestingBalance, cognitive and neurological tests that help medical staff manage and diagnose a concussion.

ConcussionIf you show signs of a concussion, NCAA rules require that you be removed from play and medically evaluated.

RecoveryYour school has a concussion management plan, and team physicians and athletic trainers are required to follow that plan during your recovery.

Return to LearnReturn to school should be done in a step-by-step progression in which adjustments are made as needed to manage your symptoms.

Return to PlayReturn to play only happens after you have returned to your preconcussion baseline and you’ve gone through a step-by-step progression of increasing activity.

http://www.ncaa.org/sport-science-institute/concussion

http://ncaa.org/concussion

What is sickle cell trait?

Know your sickle cell trait status.

Engage in a slow and gradual preseason conditioning regimen.

Build up your intensity slowly while training.

Set your own pace. Use adequate rest and recovery between repetitions, especially during “gassers” and intense station or “mat” drills.

Avoid pushing with all-out exertion longer than two to three minutes without a rest interval or a breather.

If you experience symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness, stop the activity immediately and notify your athletic trainer and/or coach.

Stay well hydrated at all times, especially in hot and humid conditions.

Avoid using high-caffeine energy drinks or supplements, or other stimulants, as they may contribute to dehydration.

Maintain proper asthma management.

Refrain from extreme exercise during acute illness, if feeling ill, or while experiencing a fever.

Beware when adjusting to a change in altitude, e.g., a rise in altitude of as little as 2,000 feet. Modify your training and request that supplemental oxygen be available to you.

Seek prompt medical care when experiencing unusual physical distress.

People at high risk for having sickle cell trait are those whose ancestors come from Africa, South or Central America, India, Saudi Arabia and Caribbean and Mediterranean countries.

sickle cell trait is not a disease. Sickle cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Sickle cell trait will not turn into the disease. Sickle cell trait is a life-long condition that will not change over time.

A FAct Sheet For Student-AthleteS

Do you knoW if you have sickle cell trait?

hoW can i Prevent a collaPse?

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SICKLE CELL TRAITDuring intense exercise, red blood cells containing the sickle hemoglobin can change shape from round to quarter-moon, or “sickle.”

Sickled red cells may accumulate in the bloodstream during intense exercise, blocking normal blood flow to the tissues and muscles.

During intense exercise, athletes with sickle cell trait have experienced significant physical distress, collapsed and even died.

Heat, dehydration, altitude and asthma can increase the risk for and worsen complications associated with sickle cell trait, even when exercise is not intense.

Athletes with sickle cell trait should not be excluded from participation as precautions can be put into place.

Sickle cell trait occurs in about 8 percent of the U.S. African-American population, and between one in 2,000 to one in 10,000 in the Caucasian population.

Most U.S. states test at birth, but most athletes with sickle cell trait don’t know they have it.

The NCAA recommends that athletics departments confirm the sickle cell trait status in all student-athletes.

Knowledge of sickle cell trait status can be a gateway to education and simple precautions that may prevent collapse among athletes with sickle cell trait, allowing you to thrive in your sport.

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For more information and resources, visit www.NCAA.org/health-safety

university of alabama at birmingham department of ... · 5/2/2018 · the university of alabama at...

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