Download EL CAMINO COLLEGE ATHLETIC TRAINING

EL CAMINO COLLEGE ATHLETIC TRAINING
Form AT-4
EL
RETURNING ATHLETE RECERTIFICATION PHYSICAL EXAMINATION
Last Name:
Male:
First Name:
Sport:
Female:
Has your insurance coverage changed since your last pre-participation physical exam? YES
Insurance Company:
NO
Group/Policy #
**Note – this information will be kept CONFIDENTIAL**
SINCE YOUR LAST PHYSICAL EXAMINATION……………………
Have you had an injury to the following areas:
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
1. Shoulder or elbow?
2. Hand or wrist?
3. Hip?
4. Knee?
5. Lower leg?
6. Ankle or foot?
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
7. Diabetes? Insulin-dependent or Non-insulin-dependent?
8. Kidney disease?
9. Epilepsy?
10. A hernia?
11. Scoliosis?
12. High blood pressure?
13. Asthma?
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
14. Had a serious injury or illness or been hospitalized?
15. Had an x-ray, MRI, CT scan or any other diagnostic testing?
16. Had a concussion and/or head injury?
17. Been unconscious for any reason other than anesthesia?
18. Had frequent headaches?
19. Had a neck and/or back injury?
20. Had a history of burners, stingers, numbness in neck, shoulder, and/or hand?
21. Had any surgical operations?
22. Completed or are you currently undergoing physical therapy or rehabilitation for an injury?
23. Had a history of anorexia, bulimia, and/or any other eating disorder?
24. Had any dental injuries? (i.e. implants, bridge, partials, or dentures)
25. Had an unfavorable/allergic reaction to a drug, antibiotic, and/or medicine?
26. Do you have any allergies? (food, bee stings, medication, etc.)
27. Are you taking any medications? (ADHD, ADD, depression, asthma, etc.)
28. Do you take vitamins, amino acids, creatine, and/or any other dietary supplement?
29. Been recently told by a physician that you have infectious mononucleosis (“mono”), hepatitis B
or C, HIV/AIDS, and/or any other severe infectious disease/viral infection?
30. Had heat related illness? (cramps, heat exhaustion, and/or heat stroke)
31. Suffered from a “racing heart”, severe chest pain, lightheadedness, or fainted while exercising?
32. Felt dizzy or passed out during or after exercise?
33. Had trouble with coughing, wheezing, or breathing during or after exercise?
34. Been told by a physician to restrict your activity or not to participate in sport?
Have you been told by a physician that you have:
Have you?
1
EL CAMINO COLLEGE ATHLETIC TRAINING
Form AT-4
EL
**FEMALES ONLY**
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
1. Is your menstrual cycle regular?
2. Do you have abnormal menstrual flow?
3. Have you ever failed to menstruate for more than 3 consecutive months?
4. Have you had any pregnancies and/or births?
5. Are you currently on birth control?
If you answered “yes” to any of the above questions please explain in the box provided. Include
the question number with your comment.
Verification Signature
I have verified that the responses in this recertification physical exam form are correct to the best of my knowledge/belief. This physical
exam will remain valid for one year. I understand that they will be used to:
•
•
•
Provide medical information to emergency medical personnel or facilities if I require emergency services
Determine my fitness ability to participate in the sport(s) I have listed in this recertification form
Complete and process insurance claim forms
I understand that failure to disclose a preexisting condition/injury/illness may result in:
1.
2.
El Camino College’s Insurance Policy excluding or limiting benefits for re-injury of the preexisting, undisclosed condition.
Termination of my athletic eligibility.
Student/Athlete Signature:
Date:
Parent Signature (if under 18 years of age):
Date:
**FOR OFFICIAL USE ONLY**
BLOOD PRESSURE _______________ PULSE _________ WEIGHT ________
CLEARED: YES ____ NO ____
COMMENTS: _________________________________________________
ATC Signature:
Date:
2