Download Physical Examinations - University of West Florida

Medical History and Technical Standards Form
Physical Examinations
Effective with the 2001-2002 UWF Catalog, any student applying to enter the Athletic Training
Education Program must complete a comprehensive physical examination by a licensed
physician. Students who are currently in the program and/or are classified under a previous
academic year catalog are not required (but highly recommended) to complete a physical
examination.
Each student must assume the costs associated with the initial physical examination prior to
admission. The physical examination may be obtained by the UWF Student Health Services,
local physician, or the student’s primary care physician.
Effective with the application process for entry into the Athletic Training Education Program
for the 2002-2003 academic year, each student must read and sign the “Technical Standards
for Athletic Training Students” document that will be included with the physical examination
and medical history forms that follow.
Physical Activity Definition
Physical Activity (Preferred Usage)
Physical activity consists of athletic, recreational or occupational activities that require
physical skills and utilize strength, power, endurance, speed, flexibility, range of motion or
agility.
Physically Active
Physically active individuals engage in athletic, recreational or occupational activities that
require physical skills and utilize strength, power, endurance, speed, flexibility, range of
motion or agility.
Medical History and Technical Standards Form
MEDICAL HISTORY FORM
THIS INFORMATION IS FOR OFFICIAL AND MEDICALLY-CONFIDENTIAL USE ONLY AND WILL
NOT BE RELEASED TO UNAUTHORIZED PERSONS
Name:_________________________
Sport:______________________________________
Have you ever (Check each item. If yes, please explain)
YES
NO
Explanation of Yes Responses:
Lived with anyone with
tuberculosis
Coughed up blood
Used tobacco products
Worn a brace or back support
Do you (Check each item. If yes, please explain)
YES
Explanation of Yes Responses:
NO
Wear a hearing aid
Wear glasses/contact lenses
Take any medications
Have any allergies
Have you ever had or do you have now (please check at left of each item)
YES
NO
YES
NO
YES
NO
Swollen or painful joints
Chronic cough
Frequent or severe headache
Palpitation or pounding heart
Gastrointestinal trouble
Gallstones/gall bladder
trouble
Dizziness or fainting spells
Leg cramps
Motion sickness
Eye trouble
Paralysis
Depression or excessive worry
Ear, nose, or throat trouble
Epilepsy or convulsions
Loss of memory
Hearing loss
Jaundice or hepatitis
Periods of unconsciousness
Chronic or frequent colds
Frequent trouble sleeping
Dental problems
Sinusitis
Tumor, growth, cyst, cancer
Diabetes
Hay Fever
Hernia
Organs missing
Head Injury
Hemorrhoids
Heat exhaustion/stroke
Skin disease
Frequent or painful urination
Arthritis or Rheumatism
Thyroid trouble
Kidney stone or blood in urine
Female disorders
Tuberculosis
Recent gain or loss of weight
Changes in menstrual pattern
Asthma
Heart trouble
Frequent indigestion
Shortness of breath
High or low blood pressure
Pain or pressure in chest
Medical History and Technical Standards Form
Have you ever (Check each item. If yes, please
explain.)
YES
NO
Explanation of Yes
Responses:
1. been withheld from physical
activity because of injury or
illness?
2. had or been advised to have
an operation?
3. been a patient in a hospital?
4. consulted or been treated by
clinics, physicians, healers, or
other practicioners within the
past five years for other than
minor illness?
5. suffered a head or neck injury?
6. suffered from a shoulder, elbow,
wrist, or hand injury?
7. suffered from a hip, knee, ankle,
or foot injury?
8. had an injury other than those
already noted?
Does your family have a history of:
YES
NO
If yes, what
relation?
Diabetes
High blood pressure
Heart attacks or strokes
Cancer
I certify that I have reviewed the above information and that it is true and complete to
the best of my knowledge. I understand that the results of the physical examination does
not guarantee admission into this Athletic Training Education Program.
Signature of Student
Printed Name
Date
Medical History and Technical Standards Form
TECHNICAL STANDARDS FOR ADMISSION
The Athletic Training Education Program at the University of West Florida is a rigorous and
intense program that places specific requirements and demands on the students enrolled in
the program. An objective of this program is to prepare graduates to enter a variety of
employment settings and to render care to a wide spectrum of individuals engaged in
physical activity. The technical standards set forth by the Athletic Training Education
Program establish the essential qualities considered necessary for students admitted to this
program to achieve the knowledge, skills, and competencies of an entry-level athletic
trainer, as well as fulfill certain standards and guidelines set forth by the Commission on
Accreditation of Allied Health Education Programs [CAAHEP] for this program to achieve
accreditation as an undergraduate athletic training education program. The following
abilities and expectations must be met by all students admitted to the Athletic Training
Education Program. In the event a student is unable to fulfill these technical standards,
with or without reasonable accommodation, the student will not be admitted into the
program.
Compliance with the program’s technical standards does not guarantee a student’s eligibility
for the NATABOC certification exam.
Candidates for selection to the Athletic Training Education Program must demonstrate:
1. the mental capacity to assimilate, analyze, synthesize, integrate concepts and problem
solve to formulate assessment and therapeutic judgments and to be able to distinguish
deviations from the norm.
2. sufficient postural and neuromuscular control, sensory function, and coordination to
perform appropriate physical examinations using accepted techniques; and accurately,
safely and efficiently use equipment and materials during the assessment and treatment
of patients.
3. the ability to communicate effectively and sensitively with patients and colleagues, including
individuals from different cultural and social backgrounds; this includes, but is not limited to,
the ability to establish rapport with patients and communicate judgments and treatment
information effectively. Students must be able to understand and speak the English language
at a level consistent with competent professional practice.
4. the ability to record the physical examination results and a treatment plan clearly and
accurately.
5. the capacity to maintain composure and continue to function well during periods of high
stress.
6. the perseverance, diligence and commitment to complete the athletic training education
program as outlined and sequenced.
7. flexibility and the ability to adjust to changing situations and uncertainty in clinical
situations.
8. affective skills and appropriate demeanor and rapport that relate to professional education
and quality patient care.
Candidates for selection to the Athletic Training Education Program will be required to
verify they understand and meet these technical standards or that they believe that, with
certain accommodations, they can meet the standards.
The Student Disability Resource Center, (phone #850.474.2387, or uwf.edu/sdrc) will evaluate
a student who states he/she could meet the program’s technical standards with
accommodation and confirm that the stated condition qualifies as a disability under applicable
laws.
Medical History and Technical Standards Form
If a student states he/she can meet the technical standards with accommodation, then the
University will determine whether it agrees that the student can meet the technical standards
with reasonable accommodation; this includes a review a whether the accommodations
requested are reasonable, taking into account whether accommodation would jeopardize
clinician/patient safety, or the educational process of the student or the institution, including
all coursework, clinical experiences and internships deemed essential to graduation.
READ AND SIGN ONLY ONE STATEMENT BELOW:
I certify that I have read and understand the technical standards for selection listed above, and
I believe to the best of my knowledge that I meet each of these standards without
accommodation. I understand that if I am unable to meet these standards I will not be
admitted into the program.
________________________________
Signature of Applicant
Date
____________
I certify that I have read and understand the technical standards of selection listed above and I
believe to the best of my knowledge that I can meet each of these standards with certain
accommodations. I will contact the SDRC Office (phone #850.474.2387, or uwf.edu/sdrc) to
determine what accommodations may be available. I understand that if I am unable to meet
these standards with or without accommodations, I will not be admitted into the program.
________________________________
Signature of Applicant
____________
Date