Download Hello, Club Sport Athlete! - ASU Students

Hello, Club Sport Athlete!
Welcome to Arizona State University Club Sports! I hope you enjoyed your summer and
are ready for a great season of competition. My name is Dr. Anne Garrison, and I am your new team
physician for the club sports. I am board certified in both family medicine and sports medicine. There are
going to be some exciting changes to your medical care this fall! We are modeling our care system to
offer you the same care that is provided at the NCAA Division I level. Briefly, what this means to you:
1. I have office hours Monday-Friday at the Student Recreation Complex Either myself or
one of my Sports Medicine physicians colleagues will staff this office.
2. I am able to manage both your musculoskeletal AND medical issues to help minimize
time away from participation and ensure your safe return to play.
3. Your certified athletic trainers (Jaime McClelland and Nicole Wilke) will have training
room hours Tuesday and Thursday mornings at the SRC – for complimentary initial
evaluation/triage of injuries.
4. I will be in close communication with your athletic trainers and coaches to help facilitate
your rehab and return to play.
5. Most club athletes are now required to undergo a pre-participation evaluation (PPE). If
you received these forms, a PPE physical exam is required for your sport. The primary
purpose of the PPE is to assess your health risk for participation in club sports. By
performing a full musculoskeletal exam during your PPE, we can identify potential areas
of injury and find ways to work with the trainers and coaches to decrease your risk for
injury.
6. To maximize and streamline your care, it is preferred that you schedule this PPE physical
exam with me or another ASU team physician. Please call the Campus Health
Appointment line (480-965-3349) to schedule your pre-participation physical at your
earliest convience. You may also go to another Arizona licensed provider who must use
the attached forms. Forms may be dropped off at Campus Health Services or faxed to
me 480-965-4179. After reviewing your forms, you may still need to follow up with an
ASU Sports Medicine team physician
7. If you participate in a sport that carries a high risk for concussion (insert the actual sports
here), you will need to sign the concussion acknowledgement form, receive information
about concussion symptoms, and undergo baseline computerized neurocognitive
testing, called ImPACT as we do for our NCAA athletes.This test takes about 30 minutes
and evaluates your memory, attention span, problem solving ability, and reaction time. If
you sustain a concussion during the season, we will then repeat the test and compare
those results to your baseline to help guide your safe return to play. You may be able to
have ImPACT testing during your physical or scheduled separately.
8. If you are in a sport that is at risk for heat injuries, similar to NCAA policy you will get
screened for sickle cell trait. You will still be able to participate if you test positive,
however, we will get you and your coach information on how to participate safely.
I have attached the pre-participation physical paperwork for you to review, fill out, and sign. Please
contact me if you have any questions. I look forward to meeting you!
Anne M. Garrison, DO
Club Sports Team Physician
[email protected]
Club Athlete Check Off List
Please ensure you have the following
with you for your appointment:
___ ASU ID card
___ Insurance card
___Emergency contact information (page 3)
___ Past medical history forms filled out completely and signed by athlete,
and parent/guardian if athlete under age 18 (pages 4-8) prior to physical
and take to your appointment
___*Concussion fact sheet reviewed by athlete
___*Concussion acknowledgement form signed by athlete, and
parent/guardian if athlete under age 18
___Sickle cell trait fact sheet reviewed by athlete
___Sickle cell trait acknowledgement form signed by athlete, and
parent/guardian if athlete under age 18
___ MUST include copy of sickle cell screening lab test results if exam is
performed by another provider in the state of Arizona (instead of ASU team
physician)
___Campus Health consent to treat form signed by parent or guardian if
athlete under age 18
*For concussion high risk sports athletes
SRC Sports Medicine
Fax: 480-965-4179
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Emergency Contact Information
Name (last, first)
Preferred name
ASU ID
SPORT
AGE
Date of Birth
Cell Phone
(
)
EMERGENCY CONTACT INFORMATION:
Name:
Relation to you:
Phone:
If the person(s) listed above are NOT local in the Phoenix area, please list an additional
local emergency contact:
Name:
Relation to you:
Phone:
Team Physician Notes:
Allergies:
Significant Medical Issues:
SRC Sports Medicine
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FIRST NAME____________________________________________
LAST NAME_____________________________________________
ASU ID#_______________________________________________
ARIZONA STATE UNIVERSITY
DATE OF BIRTH _________________________________________
SPORTS MEDICINE
SPORT___________________________ Jersey Number__________
CLUB SPORTS PHYSICAL
Year in School (circle one)
Freshman
Sophomore
Junior
Gender (circle one) Male
Senior
Female
5th year Non-Student participant
Current Age _____yrs
Do you take any pills, supplements, vitamins or medication (including inhalers and birth
control pills)? Please list:
What medicines are you allergic to? What happens when you take that medicine?
Medicine
Reaction
Musculoskeletal Problems:
Body Part
Sprain / Strain /
Fracture / Other
Year
Management
Fingers/Wrist/Hand
Elbow
Shoulder
Hip
Knee
Ankle
Foot
SRC Sports Medicine
Fax: 480-965-4179
Page 4
Athlete Name/Date of Birth__________________
What medical problems do you have? What problems are in your family? Please
specify other family members:
You
Family
Member(s)
Comments
High Blood
Pressure
Heart Murmur
Heart Disease/
Heart Attack
Epilepsy/Seizures
Asthma/ Exercise
Induced
Bronchospasm
Valley Fever
Mononucleosis
Headaches
Hepatitis
Anemia
Bleed/Bruise
Easily
Cancer
Eating Disorder
Thalessemia
Sickle Cell
Kidney/Bladder
Infection or
stones
Thyroid
Depression/
Bipolar
ADD/ADHD
Other
Immunization History
Vaccine
Chicken Pox
Gardisil(HPV)
Hepatitis A
Hepatitis B
Tetanus
Meningitis
SRC Sports Medicine
Number of shots needed
Number of shots received
and dates if known
1
3
2
3
Every 10 years
1
Fax: 480-965-4179
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Athlete Name/Date of Birth__________________
Are you allergic to any insect bites or stings?
Do you need an epi-pen for an allergic reaction?
Does anyone in your family have heart disease, a pacemaker, or
defibrillator?
Have you, or any family member, been diagnosed with Marfans Syndrome?
If yes, who:
Have you, or any family member been diagnosed with Hypertrophic
cardiomyopathy?
If YES, who:
Has anyone in your family died before the age of 50?
Does anyone in your family have sickle cell disease or sickle cell trait?
If YES, who:
Have you ever been told you have a heart murmur?
Have you ever been told you have a heart problem?
Have you ever passed out, or almost passed out, during exercise?
Have you ever had chest pain, chest tightness, chest pressure or
discomfort during exercise?
Have you ever felt your heart racing or skipping beats during exercise?
Have you ever been diagnosed with asthma or exercise induced bronchial
spasms?
Have you ever used an inhaler?
After hard work-outs do you experience coughing or wheezing?
Have you had a herpes or MRSA skin infection?
Have you ever been dizzy, during or after exercise?
Have you ever been dizzy or passed out in the heat?
Have you ever had a head injury or a concussion?
If YES, how many?
Have you ever had a blow, or hit to the head, that caused confusion,
prolonged headache or memory problems?
Have you ever been knocked unconscious?
Have you ever had a stinger or burner?
Have you ever had a seizure?
Do you have any problems with your eyes or with your vision?
Do you wear glasses or contacts?
Would you like to change your weight?
Do you follow any special diet?
Do you avoid any certain foods?
Have you been treated by a physician or other health care provider in the
last 12 months?
If YES, for what?
YES
YES
YES
NO
NO
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
Examiner notes:
SRC Sports Medicine
Fax: 480-965-4179
Page 6
Athlete Name/Date of Birth__________________
Have you recently been thinking about hurting yourself or suicide
Have you recently been thinking about hurting/killing someone else
Have you ever missed work, school or your sport because of an
emotional issue?
Have you or anyone in your family been treated for alcohol or
substance abuse?
Have you ever fractured (broken) a bone or dislocated a joint?
Have you ever had a stress fracture?
Have you every injured a bone, muscle, ligament or tendon that
caused you to miss practice or a game?
Do you wear any special or additional bracing/taping etc during
sports participation?
If YES, what?
Has your participation in sports ever been restricted or denied for
any reason?
Do you use tobacco? If yes, what type?
How Much & How Often?
Did you formerly use tobacco?
If yes, what type?
Quit date:
Do you drink alcohol?
If yes, how many drinks?
How often?
Did you formerly use alcohol?
If yes, quit date:
Do you use any illicit or street drugs?
Are you, or have you ever been, sexually active?
If yes, do you use condoms (circle one):
Sometimes Always Never
Birth control method(s): (circle all that apply):
Abstinence Withdrawal Contraceptive Pills IUD Condoms
YES
YES
YES
NO
NO
NO
YES
NO
YES
YES
YES
NO
NO
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
YES
NO
NO
Depo-Provera
Over the past 2 weeks, how often have you been bothered by the following
problems:
Not at
Several More than
Nearly
all
days
half the
every day
days
Little interest or pleasure in doing things
0
1
2
3
Feeling down, depressed or hopeless
0
1
2
3
FEMALES:
How old were you, when you started having periods?
How many periods have you had in the last 12 months?
yrs
Examiner notes:
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I hereby state, that, to the best of my knowledge, my answers to the above
questions are complete and correct.
Athlete name_____________________________________ Date_______________
Athlete signature__________________________________
Athlete club sport__________________________________
ASU ID number___________________________________
Parent, or legal guardian, Signature (if athlete under 18):
______________________________________________
SRC Sports Medicine
Fax: 480-965-4179
Date______________
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Athlete Name/Date of Birth__________________
PHYSICAL EXAM (Page 1 of 3)
HT______WT________B/P_____/_____HR______
Gender: Male Female
Peak Flow_________
MEDICAL EXAM
Appearance
EYES
NORMAL
Vision R ____/20 L_____/20
Corrected: Glasses Contacts
ABNORMAL FINDINGS
EOMI
Pupils
HEENT
Neck
Lymph nodes
Heart
Murmurs
Standing/Supine/Valsalva
PMI
Pulses
Lungs
Abdomen
Genitourinary
(males)
Skin
Neuro
Please include copy of sickle cell screening lab test results or waiver form.
Examiner Notes for any abnormal findings above:
Examiner Name
SRC Sports Medicine
Signature
Fax: 480-965-4179
Date
Page 9
PHYSICAL EXAM (Page 2 of 3)
MUSCULOSKELETAL
EXAM
Neck: ROM
Normal
Athlete Name/Date of Birth_____________
Abnormal Findings
Spurlings
Back: Curve
ROM
Shoulder: ROM
Strength
If indicated:
Tenderness
Impingement
Speeds
O’Briens
Laxity
Apprehension/Relocation
Elbow: ROM
Strength
If indicated:
Tenderness
Valgus/varus stability
Wrist/Hand: ROM
Strength
Opposition/Arachnodactyly
Tenderness
Hip/Pelvis: ROM
Flexibility
FABER
Strength
If indicated:
Tenderness
Obers
Knee: ROM
Strength
Squat
If indicated:
Tenderness
Apprehension
Valgus/varus stability
Lachmans
Anterior/posterior drawer
McMurray
Ankle: ROM
Single leg balance
If indicated:
Tenderness
Anterior drawer
Talar tilt
Klieger
Foot: Arch
Tenderness
Other:
Examiner Name
SRC Sports Medicine
Signature
Fax: 480-965-4179
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Patient Name/Date of Birth__________________
ATHLETE NAME________________________________
CLUB SPORT_____________________________
__________May participate in the above sports club without restrictions
__________Needs the following work-up before being able to participate:
Recommendations:
___ Sickle screen
___ ImPACT testing (for high concussion risk sports)
___Hepatitis B vaccine series
___Previous records
___ X-rays
___ Other
__________Is NOT able to participate for the indicated club sports at this time
Physician Name______________________________________________
Physician Signature___________________________________________
Physician Address ___________________________________________
___________________________________________
Physician Fax (______)___________________
Date_____________________
SRC Sports Medicine
Fax: 480-965-4179
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ARIZONA STATE UNIVERSITY
SPORTS MEDICINE
Sickle Cell Trait Testing Consent / Refusal and Release
Sickle Cell Trait is a genetically inherited condition that affects red blood cells during intense exercise.
NCAA student-athletes with sickle cell trait have experienced significant physical distress during extreme
conditioning and some have even died. Those student-athletes who have Sickle Cell Trait and who
participate in high risk club sports including but not limited to: American Pankration, Cheer,
Equestrian, Field Hockey, Gymnastics, Ice Hockey, Lacrosse, Rugby, Soccer, Tae Kwon Do, Water
Polo, and Water Skiing are at higher risk of complications during training. Certain student-athletes
are at higher risk of having this condition, specifically students who are of African-American and
Hispanic descent.
The Arizona State University (ASU) Department of Student Recreation (SRC) or ASU Health Services
(AHS) has provided me with educational materials regarding Sickle Cell Trait and the risks associated
therewith and has offered me testing for Sickle Cell Trait. I understand ASU requires that ALL
incoming club sport athletes be tested for Sickle Cell Trait, provide documented results of a prior test to
ICA or decline the test and sign a waiver releasing ASU from liability. I also understand that ASU
requires all participants in high risk club sports to undergo testing prior to participation.
I acknowledge and understand that if I test positive for Sickle Cell Trait, I will NOT be restricted from
playing my sport. However, for my health and safety, certain precautions will be taken with respect to
my training and I will be removed from training if I develop symptoms associated with Sickle Cell Trait.
I acknowledge that I have had a full opportunity to ask any questions I have about the diagnosis of Sickle
Cell Trait and the ASU Sickle Cell Trait testing program and to discuss the risks associated with
participation in intercollegiate athletics at ASU if I have Sickle Cell Trait. Any questions or concerns I
had, if any, have been addressed to my satisfaction. I understand the risks involved if I choose NOT to be
tested for Sickle Cell Trait, and I knowingly assume such risks.
(Please initial one line below)
_____ I have received this information and I AGREE to be tested for Sickle Cell Trait.
_____ I HAVE SHOWN ASU the results of a prior Sickle Cell Trait test.
_____ I have received this information, do not participate in a high risk sport, and I DECLINE a blood
test for Sickle Cell Trait. I understand that by refusing to undergo screening for Sickle Cell Trait, I
assume all risks associated with such refusal and, in consideration for being granted the opportunity to
participate in club sports at ASU without agreeing to be tested for Sickle Cell Trait, I (for myself, my
executors, administrators and assigns) hereby release and forever discharge Arizona State University, the
Arizona Board of Regents and the State of Arizona and their regents, officers, employees, agents,
representatives, coaches, physicians, instructors and volunteers from any and all liability, actions, causes
of action, debts, claims or demands of any kind and nature directly or indirectly related to any personal
injury, including death, bodily injury, mental anguish or emotional distress that I may suffer related in any
way to my participation in intercollegiate athletics, whether caused by my negligence or carelessness or
the negligence of ASU or otherwise. These risks have been discussed with me and I have made this
decision on a fully informed basis. I understand that this release means that, among other things, I am
giving up my right to sue Arizona State University for any such losses, damages, injury or costs that I
may incur.
SRC Sports Medicine
Fax: 480-965-4179
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I represent and certify that I am at least 18 years old and that I have read the entirety of this document and
fully understand the contents, consequences and implications of signing this document and that I agree to
be legally bound by this document.
Athlete (If under 18, a parent or legal guardian must print and sign name below):
Print Name:_________________________ Signature:__________________________
Date:___________
If under 18, parent or legal guardian must print and sign name below and indicate date signed.
Print Name:_________________________ Signature:__________________________
Date:___________
Witness:
Print Name:_________________________ Signature________________________ __
Date:___________
SRC Sports Medicine
Fax: 480-965-4179
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Arizona State University
Mild Traumatic Brain Injury (MTBI) / Concussion
Statement and Acknowledgement Form
I, __________________________, acknowledge that I have to be an active participant in my own healthcare and
have the direct responsibility for reporting all of my injuries and illnesses to the Sports Medicine staff at ASU (e.g.,
team physician, athletic training staff). I further recognize that my physical condition is dependent upon providing
to the ASU Sports Medicine staff an accurate medical history and a full disclosure of any symptoms, complaints,
prior injuries and/or disabilities experienced before, during or after athletic activities.
By signing below, I acknowledge:
That ASU has provided me with specific educational materials (including the NCAA Concussion Fact
Sheet) on what a concussion is and has given me an opportunity to ask questions regarding such materials.
That I have fully disclosed to the Sports Medicine staff any prior medical conditions and will disclose any
future conditions.
There is a possibility that participation in my sport may result in a head injury and/or concussion. In rare
cases, a concussion can cause permanent brain damage, and even death.
A concussion is a brain injury, which I am responsible for reporting to the team physician or athletic
trainer.
A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance,
sleep, and classroom performance.
Some of the symptoms of concussion may be noticed right away while other symptoms can show up hours
or days after the injury.
If I suspect a teammate has a concussion, I am responsible for reporting the injury to my team physician or
athletic trainer.
I will not return to play in a game or practice if I have received a blow to the head or body that results in
concussion-related symptoms.
I will not return to play in a game or practice until my symptoms have resolved AND I have been cleared to
do so by a team physician.
Following concussion the brain needs time to heal and I am much more likely to have a repeat concussion
or further damage if I return to play before my symptoms resolve.
Based on the incidence of concussion as published by the NCAA, the following sports have been identified as high
risk for concussion: baseball, basketball, diving, equestrian, field hockey, football, gymnastics, ice hockey, lacrosse,
pole vaulting, rugby, soccer, softball, water polo, and wrestling. Arizona State University requires a baseline neurocognitive test for all students participating in these sports, and other individual students or teams as determined by
the team physician, prior to participation in the first practice.
I represent and certify that I am at least 18 years old and that I have read the entirety of this document and fully
understand the contents, consequences and implications of signing this document and that I agree to be legally
bound by this document.
Athlete (If under 18, a parent or legal guardian must print and sign name below):
Print Name: _________________________ Signature: __________________________ Date: ___________
If under 18, parent or legal guardian must print and sign name below and indicate date signed.
Print Name: _________________________ Signature: __________________________ Date: ___________
SRC Sports Medicine
Fax: 480-965-4179
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