Assumption College Department of Athletics

2007-2008 Health-Status Questionnaire

NOTE TO ALL INCOMING FRESHMEN AND TRANSFER STUDENTS: This form is NOT a medical record. A separate medical record must be completed and sent to Student Health Services in order to be medically cleared for school and to participate in varsity athletics. A copy of this medical record will be forwarded to the Sports Medicine Department.

Participation in sports requires an acceptance of risk of injury. Athletes rightfully assume that those who are responsible for the conduct of sport have taken reasonable precautions to minimize the risk of significant injury and that those participating in the sport will not intentionally inflict injury.

The National Collegiate Athletic Association's (N.C.A.A.) policies recommend that all student-athletes have qualifying medical evaluations upon their initial entrance into an institution's intercollegiate athletics program. Assumption College supports and adheres to this N.C.A.A. policy. Further medical evaluations (subsequent to the initial qualifying exam) may be required in specific cases. This annual from must be completed and returned before an athlete will be permitted to practice or play.

PLEASE COMPLETE THIS FORM IN ITS ENTIRETY:

Sport: BaseballMen's BasketballWomen's BasketballMen's Cross CountryWomen's Cross CountryField HockeyFootballGolfIce HockeyMen's LacrosseWomen's LacrosseMen's SoccerWomen's SoccerMen's RowingWomen's RowingSoftballWomen's SwimmingMen's TennisWomen's TennisMen's Indoor TrackWomen's Indoor TrackundefinedMen's Outdoor TrackWomen's Outdoor TrackVolleyball 

Last Name:

First Name:

Middle Initial:

Select One: Freshman Sophomore Junior Senior Transfer

Date of College Admission Physical Examination:

Date of the last time you completed this form:

1. Have you been hospitalized for any reason since the above exam? Yes No
2. Are you currently ill in any way? Yes No
3. Have you had any injury, including cerebral concussion, since the above exam? Yes No
4. Have you ever been diagnosed by a physician with a cerebral concussion? Yes No

If so, how many?

1. Do you currently have any incompletely healed injury? Yes No
2. Are currently taking any medications or taking medication on a continuing basis? Yes No
3. Are you allergic to any medications, bee stings, etc? Yes No
4. Do you know of any health reason why you should not participate in varsity athletics? Yes No
5. Has your Health Insurance changed with the last year? Yes No  

If yes, please submit a copy of your new Insurance Card.

If you responded“Yes” to any of the above questions, please explain below:

The undersigned herewith,

1. Understands that he/she must refrain from practice or play while ill or injured, whether or not receiving medical treatment, and during medical treatment until he/she is discharged from treatment or is given permission by the clinical practitioner to restart participation despite continuing treatment.
2. Understands that having passed the physical examination does not necessarily mean that he/she is physically qualified to engage in athletics but only that the examiner did not find a medical reason to disqualify him/her at the time of said exam.
3. Certifies that the answers to all of the questions are correct and true

Emergency Contact Name:

Phone Number (with area code):

Alternate Emergency Contact:

Phone Number(with area code):

Instant Messenger Screen Name: 

Student-Athlete Signature: Date: 

(PLEASE SIGN BY UTILIZING THE LAST FOUR NUMBERS OF YOUR SOCIAL SECURITY NUMBER)