Assumption College Department of Athletics

SPORTS MEDICINE

    The information below is necessary in order for the Sports Medicine Department to have a basic knowledge of those conditions, injuries, etc. that you have had in the past or may be affecting you at present.  
    Please read all questions carefully and respond as directed.  Be as specific as possible.  The contents of this form will be kept CONFIDENTIAL by the Sports Medicine Department and will be used as supplementary information by the team physicians and athletic trainers.
    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.
    Please take the time to fill out the following information.  Student-athletes will not be allowed to participate until this form is completed.
 
Sport 

Last Name     First Name    Middle Initial 
Date of Birth 

Home Address 
City, State, ZIP 
Cell Phone (with area code) 
E-Mail Address 
Emergency Contact Name 
Phone (with area code) 
Relationship to student-athlete 

Alternate Emergency Contact Name 
Phone (with area code)  
Relationship to student-athlete 

Insurance Company
Type of Insurance (please indicate one)  HMO   PPO   Other 
Insurance Address 
Insurance Telephone (with area code) 
Policy Number 
Group Number 
Policy Holder’s Name 

Policy Number 
Policy Carrier 
Member Services Telephone (with area code)

1. Have you been hospitalized since the end of your last competitive season?    
    Yes     No
    If yes, please explain

2. Do you have any current illness or injury?
     Yes     No

    If yes, please explain

3. Have you had any injury, including concussions since the  end of your last competive season?
       Yes     No
    If yes, please explain

4. Are you allergic to stings or any medications?
      Yes     No
    If yes, please explain

5. When was the last time you saw a medical doctor?
    Date     Reason
    

6. Are you concerned with the health of your roommates, teammates or friends?
      Yes     No
    If yes, please explain

7. Would you like to speak to the Sports Medicine staff about them?
      Yes     No

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

Student-Athlete Signature (last 4 digits of your social security number)

Date