Returning Student-Athlete Health Status Report Form

The information below is necessary in order for the Sports Medicine Department to have an updated knowledge of any conditions, injuries, etc. that you sustained over the past year.  These conditions may or may not still be affecting you.  It is important that you answer the questions below to the fullest and honestly.  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.

The NCAA does not require documentation of an annual physical to continue playing intercollegiate athletics, so long as the following questionnaire is completed. The Assumption Sports Medicine Department strongly encourages student athletes to have annual physical performed by their PCP. 

Email address *
Sport *
Year of Graduation from Assumption *
Last Name *
First Name *
Date of Birth *
Home Address *
City, State, Zip Code *
Cell Phone (with area code) *
Emergency Contact Name *
Emergency Contact Phone (with area code) *
Relationship to Student-Athlete *
Alternate Emergency Contact Name *
Alternate Emergency Contact Phone (with area code) *
Relationship to Student-Athlete *

Insurance Information

Insurance Company *
Type of Insurance (please indicate one) *
If other, please list type
Insurance Address *
Insurance Telephone (with area code) *
Policy Number *
Group Number
Policy Holder's Name *

Please Answer the Following Questions

1. Please list all prescription drugs you are taking. *

2. Are you allergic to the following:

Drugs or Medication *
If yes, please list specific allergy
Foods *
If yes, please list specific allergy
Insects or Animals *
If yes, please list specific allergy
Plants, Pollen, etc. *
If yes, please list specific allergy
Other *
If yes, please list specific allergy
Please provide any further information about above listed allergies including medications and treatments use:

General Medical History

3. Are you currently being treated for an athletic injury sustained this past season? *
4. Do you have any ongoing medical conditions not athletically related? *
5. Did you for any reason visit the hospital in the past 12 months? *
6. Have you had a general physical in the past 12 months? *
7. Would you like to speak with a member of the sports medicine staff for any reason? *
If you answered yes to any of the above questions please provide further information including specific condition, date of diagnosis or treatment and duration of injury condition.

Heart Health Questions About You (in the past 12 months)

8. Have you ever passed out or nearly passed out DURING or AFTER exercise? *
9. Have you ever had discomfort, pain tightness, or pressure in your chest during exercise? *
10. Does your heart ever race or skip beats (irregular beats) during exercise? *
11. Has a doctor ever told you that you have any heart problems? Including but not limited to high blood pressure, high cholesterol, heart murmur, heart infection, rheumatic fever, Kawasaki disease, or any other heart or vascular problems? *
12. Has a doctor ever ordered a test for your heart? (ECG/EKG, echocardiogram) *
13. Do you get lightheaded or feel more short of breath than expected during exercise? *
14. Have you ever had an unexplained seizure? *
15. Do you get more tired or short of breath more quickly than your friends during exercise? *
If you answered yes to any of the above questions please explain in the space below:

Head Injury and Concussion History (in the past 12 months)

16. Did you suffer a concussion with or without loss of consciousness? *
17. Did you ever get knocked unconscious? *
18. If yes, did you report your injury to the Sports Medicine Staff? *
If you answered yes to any of the above questions, please explain in the space below:

The undersigned herewith,

1. Certifies that the answers to all of the questions are correct and true.

2. Understands the expectation laid out in the Liability Release Waiver, that all student athletes are required to have read and signed.

3. Consents to treatment by Assumption College Sports Medicine staff.

4. Understands that my primary insurance plan is ultimately responsible for fees associated with outside medical services if necessary.  This in accordance with the Assumption College Athletics Department Accident Insurance Policy, that all student athletes are required to have read and signed.

5. Understands the completion of the above questions does not guarantee clearance for participation in intercollegiate athletics at Assumption College. If I have had an injury in the past twelve months that has removed me from participation for any length of time, I must submit written documentation of clearance for intercollegiate athletic participation from the physician who is, or has managed, my injury.  If I have an ongoing medical condition (i.e. seizure disorder, heart murmur, sickle cell, cardiac conditions) I must submit documentation that I am cleared to participate in intercollegiate athletic activity. 

The Assumption College Sports Medicine Department’s athletic trainers and team physician have the final decision regarding clearance for participation in intercollegiate athletics.

Student-Athlete Signature *
(last 4 digits of your social security number)
Date *
* = required field