Download Sports Physical Packet

Sports Physical Paperwork Check Off Sheet
Hello Parents and Students,
Below you are receiving all of the paperwork that your athlete will need for the 20162017 season. In order for your student to participate, all of the forms attached will need to be
returned to the Coach of each sport. It is advised that you make a copy of all forms, especially
the physical. If your athlete plays multiple sports, you should copy all of the forms because each
coach will need the paperwork. There will not be free sports screenings this year. You can get a
physical from your primary care doctor, or any other walk-in clinic available to you (Kroger’s
Little Clinic). The physical must be dated after APRIL 15th, 2016 regardless of if you have a
physical on file from last year. Please check all of the paperwork before turning it in to ensure
that you, your athlete, and the physician have signed all necessary paperwork BEFORE turning it
into the Coaches. Any additional papers given with this packet do not need to be returned to
coaches.
All of the following must be returned to the Coaches in order for your child to be allowed to
participate:
Physical that is signed by:
The Parent
The Athlete
The Physician
Emergency Treatment Form (Consent for Athletic Participation & Medical Care)
Concussion Form (Student-athlete &Parent/Legal Guardian Concussion Statement)
HIPAA Form (Vanderbilt University Medical Center Notice of Privacy Practices
Acknowledgement)
Sudden Cardiac Form (Athlete/Parent/Guardian Sudden Cardiac Arrest Symptoms and
Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form
ImPACT Form (ImPACT and BESS Testing; it is a two-sided form. Please make sure that
both sides are properly filled out
Sign below indicating that you have reviewed all of the above information and return this sheet
with the attached paperwork.
________________________________________________
_____________________
Parent Signature
Date
■■ Preparticipation Physical Evaluation HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)
Date of Exam ____________________________________________________________________________________________________________________
Name _ __________________________________________________________________________________ Date of birth ___________________________
Sex ________ Age _ __________ Grade ______________ School ______________________________ Sport(s) ___________________________________
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies?  Yes  No If yes, please identify specific allergy below.
 Medicines
 Pollens  Food
 Stinging Insects
Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS
Yes
No
MEDICAL QUESTIONS
1. Has a doctor ever denied or restricted your participation in sports for
any reason?
26. Do you cough, wheeze, or have difficulty breathing during or
after exercise?
2. Do you have any ongoing medical conditions? If so, please identify
below:  Asthma  Anemia  Diabetes  Infections
Other: ________________________________________________
27. Have you ever used an inhaler or taken asthma medicine?
29. Were you born without or are you missing a kidney, an eye, a testicle
(males), your spleen, or any other organ?
4. Have you ever had surgery?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
Yes
No
31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or
AFTER exercise?
32. Do you have any rashes, pressure sores, or other skin problems?
6. Have you ever had discomfort, pain, tightness, or pressure in your
chest during exercise?
34. Have you ever had a head injury or concussion?
33. Have you had a herpes or MRSA skin infection?
35. Have you ever had a hit or blow to the head that caused confusion,
prolonged headache, or memory problems?
7. Does your heart ever race or skip beats (irregular beats) during exercise?
8. Has a doctor ever told you that you have any heart problems? If so,
check all that apply:
 High blood pressure
 A heart murmur
 High cholesterol
 A heart infection
 Kawasaki disease
Other:______________________
36. Do you have a history of seizure disorder?
37. Do you have headaches with exercise?
38. Have you ever had numbness, tingling, or weakness in your arms or
legs after being hit or falling?
39. Have you ever been unable to move your arms or legs after being hit
or falling?
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,
echocardiogram)
10. Do you get lightheaded or feel more short of breath than expected
during exercise?
40. Have you ever become ill while exercising in the heat?
11. Have you ever had an unexplained seizure?
42. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your friends
during exercise?
43. Have you had any problems with your eyes or vision?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
41. Do you get frequent muscle cramps when exercising?
Yes
No
13. Has any family member or relative died of heart problems or had an
unexpected or unexplained sudden death before age 50 (including
drowning, unexplained car accident, or sudden infant death syndrome)?
48. Are you trying to or has anyone recommended that you gain or
lose weight?
49. Are you on a special diet or do you avoid certain types of foods?
50. Have you ever had an eating disorder?
51. Do you have any concerns that you would like to discuss with a doctor?
FEMALES ONLY
16. Has anyone in your family had unexplained fainting, unexplained
seizures, or near drowning?
18. Have you ever had any broken or fractured bones or dislocated joints?
45. Do you wear glasses or contact lenses?
47. Do you worry about your weight?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator?
17. Have you ever had an injury to a bone, muscle, ligament, or tendon
that caused you to miss a practice or a game?
44. Have you had any eye injuries?
46. Do you wear protective eyewear, such as goggles or a face shield?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan
syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT
syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic
polymorphic ventricular tachycardia?
BONE AND JOINT QUESTIONS
No
28. Is there anyone in your family who has asthma?
3. Have you ever spent the night in the hospital?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
52. Have you ever had a menstrual period?
Yes
No
53. How old were you when you had your first menstrual period?
54. How many periods have you had in the last 12 months?
Explain “yes” answers here
19. Have you ever had an injury that required x-rays, MRI, CT scan,
­injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck
instability or atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swollen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete ___________________________________________ Signature of parent/guardian_ ____________________________________________________________ Date______________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503
9-2681/0410
■■ Preparticipation Physical Evaluation THE ATHLETE WITH SPECIAL NEEDS:
This document is only necessary when the
SUPPLEMENTAL HISTORY FORM
individual has a documented special need.
Date of Exam ____________________________________________________________________________________________________________________
Name _ __________________________________________________________________________________ Date of birth ___________________________
Sex ________ Age _ __________ Grade ______________ School ______________________________ Sport(s) ___________________________________
1. Type of disability
2. Date of disability
3. Classification (if available)
4. Cause of disability (birth, disease, accident/trauma, other)
5. List the sports you are interested in playing
Yes
No
Yes
No
6. Do you regularly use a brace, assistive device, or prosthetic?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or any other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysreflexia?
14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
Explain “yes” answers here
Please indicate if you have ever had any of the following.
Atlantoaxial instability
X-ray evaluation for atlantoaxial instability
Dislocated joints (more than one)
Easy bleeding
Enlarged spleen
Hepatitis
Osteopenia or osteoporosis
Difficulty controlling bowel
Difficulty controlling bladder
Numbness or tingling in arms or hands
Numbness or tingling in legs or feet
Weakness in arms or hands
Weakness in legs or feet
Recent change in coordination
Recent change in ability to walk
Spina bifida
Latex allergy
Explain “yes” answers here
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete ___________________________________________ Signature of parent/guardian_ __________________________________________________________ Date______________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
■■ Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM
Name _ __________________________________________________________________________________ Date of birth ___________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).
EXAMINATION
Height Weight  Male  Female
BP / ( / ) Pulse Vision R 20/ L 20/ Corrected  Y  N
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/ears/nose/throat
• Pupils equal
• Hearing
Lymph nodes
Heart a
• Murmurs (auscultation standing, supine, +/- Valsalva)
• Location of point of maximal impulse (PMI)
Pulses
• Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)b
Skin
• HSV, lesions suggestive of MRSA, tinea corporis
Neurologic c
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
• Duck-walk, single leg hop
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
Consider GU exam if in private setting. Having third party present is recommended.
Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
a
b
c
 Cleared for all sports without restriction
 Cleared for all sports without restriction with recommendations for further evaluation or treatment for __________________________________________________________________
_____________________________________________________________________________________________________________________________________________
 Not cleared
 Pending further evaluation
 For any sports
 For certain sports ______________________________________________________________________________________________________________________
Reason ____________________________________________________________________________________________________________________________
Recommendations __________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and
participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely
explained to the athlete (and parents/guardians).
Name of physician (print/type) _____________________________________________________________________________________________________ Date ________________
Address ___________________________________________________________________________________________________________ Phone _________________________
Signature of physician _______________________________________________________________________________________________________________________, MD or DO
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503
9-2681/0410
■■ Preparticipation Physical Evaluation CLEARANCE FORM
This form is for summary use in lieu of the physical exam form and health
history form and may be used when HIPAA concerns are present.
Name ___­­­­­____________________________________________________ Sex  M  F
Age _________________ Date of birth _________________
 Cleared for all sports without restriction
 Cleared for all sports without restriction with recommendations for further evaluation or treatment for ________________________________________________
___________________________________________________________________________________________________________________________
 Not cleared
 Pending further evaluation
 For any sports
 For certain sports______________________________________________________________________________________________________
Reason _ ___________________________________________________________________________________________________________
Recommendations _______________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent
clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office
and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation,
the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete
(and parents/guardians).
Name of physician (print/type) ___________________________________________________________________________________ Date ________________
Address _________________________________________________________________________________________ Phone _________________________
Signature of physician _____________________________________________________________________________________________________, MD or DO
EMERGENCY INFORMATION
Allergies _______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Other information _ _______________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
CONSENT FOR ATHLETIC PARTICIPATION & MEDICAL CARE
*Entire Page Completed By Patient
Athlete Information
Last Name______________________________
Sex: [ ] Male [ ] Female
Grade ___________
First Name ________________________
Age _______
MI _______
DOB ____/____/_____
Allergies ________________________________________________________________________________
Medications______________________________________________________________________________
Insurance ______________________________________ Policy Number ____________________________
Group Number _________________________________ Insurance Phone Number ____________________
Emergency Contact Information
Home Address ______________________________________(City)____________________(Zip)_________
Home Phone __________________ Mother’s Cell _________________ Father’s Cell __________________
Mother’s Name _____________________________________
Work Phone ________________________
Father’s Name ______________________________________
Work Phone ________________________
Another Person to Contact __________________________________________________________________
Phone Number _________________________
Relationship ___________________________
Legal/Parent Consent
I/We hereby give consent for (athlete’s name) ________________________________________ to represent
(name of school) __________________________________ in athletics realizing that such activity involves
potential for injury. I/We acknowledge that even with the best coaching, the most advanced equipment, and
strict observation of the rules, injuries are still possible. On rare occasions these injuries are severe and
result in disability, paralysis, and even death. I/We further grant permission to the school and TSSAA,
its physicians, athletic trainers, and/or EMT to render aid, treatment, medical, or surgical care deemed
reasonably necessary to the health and well being of the student athlete named above during or
resulting from participation in athletics. By the execution of this consent, the student athlete named above
and his/her parent/guardian(s) do hereby consent to screening, examination, and testing of the student athlete
during the course of the pre-participation examination by those performing the evaluation, and to the taking of
medical history information and the recording of that history and the findings and comments pertaining to the
student athlete on the forms attached hereto by those practitioners performing the examination. As parent or
legal Guardian, I/We remain fully responsible for any legal responsibility which may result from any
personal actions taken by the above named student athlete.
Signature of Athlete
Signature of Parent/Guardian
Date
CONSENTIMIENTO A PARTICIPAR EN ACTIVIDADES ATLETICAS Y RECIBIR CUIDADO
MEDICO SI FUERA NECESASRIO
(Este Consentimiento debe ser completado por el Estudiante-Atleta y sus padres o guardianes.)
Información del Estudiante-Atleta
Apellido
Nombre
Sexo: [ ] Varón [ ] Hembra
Grado__________
SN
Edad_________ Fecha de Nacimiento_____/_____/_____
Alergias
Medicaciones
Seguro Médico
Número de la Póliza
Número del Grupo
Teléfono del Seguro
Información del Contacto en Caso de Emergencia
Dirección de Casa
(Ciudad)
(Código Postal)
Teléfono de Casa
Celular de la Madre o Guardian
Celular del Padre o Guardian
Nombre de la Madre o Guardian
Teléfono del Trabajo
Nombre del Padre o Guardian
Teléfono del Trabajo
Otra Persona Contacto
Número de Teléfono
Relación
Consentimiento Legal de los Padres o Guardianes
Yo/Nosotros damos nuestro consentimiento para que (nombre del EstudianteAtleta)____________________________________ pueda representar (nombre de la
escuela)________________________________________ en deportes y que yo/nosotros entendemos que esa actividad
lleva la posibilidad de sufrir lesiones. Yo/Nosotros sabemos que aún con el mejor entrenamiento, los mejores artículos
deportivos, y la observación estricta de las reglas, es posible sufrir lesiones. En algunas ocasiones, estas lesiones
son severas y pueden resueltar en incapacidad, parálisis, y hasta la muerte. Yo/Nosotros damos permiso a la
escuela y a TSSAA, sus médicos, entrenadores atléticos, y/o técnicos médicos de emergencias a dar ayuda,
tratamiento, cuidado médico o quirúrgico considerados necesarios para la salud y bienestar del EstudianteAtleta nombrado arriba durante o como resultado de su participación en los deportes. Al firmar este
consentimiento, el Estudiante-Atleta nombrado arriba y sus padres/guardianes consienten a que los profesionales de la
salud conduzcan un chequeo, examinación, y pruebas del Estudiante-Atleta durante la examinación pre-participacipatoria
y a obtener la historia médica. Entendemos que los profesionales de la salud que conduzcan estas pruebas y
evaluaciones van a anotar los resultados y observaciones en los formularios y records que acompañan este documento.
Como padre o guardian , yo/nosotros entendemos que somos totalmente responsables por cualquier asunto legal
que pueda resultar de las acciones personales del Estudiante-Atleta nombrado arriba.
Firma del Estudiante-Atleta
Firma del Padre/Guardian
Fecha
CONCUSSION
INFORMATION AND SIGNATURE FORM
FOR STUDENT-ATHLETES & PARENTS/LEGAL GUARDIANS
(Adapted from CDC “Heads Up Concussion in Youth Sports”)
Public Chapter 148, effective January 1, 2014, requires that school and community organizations
sponsoring youth athletic activities establish guidelines to inform and educate coaches, youth athletes and
other adults involved in youth athletics about the nature, risk and symptoms of concussion/head injury.
Read and keep this page.
Sign and return the signature page.
A concussion is a type of traumatic brain injury that changes the way the brain normally works. A
concussion is caused by a bump, blow or jolt to the head or body that causes the head and brain to move
rapidly back and forth. Even a “ding,” “getting your bell rung” or what seems to be a mild bump or blow
to the head can be serious.
Did You Know?
•
•
•
Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for
another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than
adults.
WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?
Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed
until days or weeks after the injury.
If an athlete reports one or more symptoms of concussion listed below after a bump, blow or jolt to the
head or body, s/he should be kept out of play the day of the injury and until a health care provider* says
s/he is symptom-free and it’s OK to return to play.
SIGNS OBSERVED BY COACHING STAFF
Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score or opponent
Moves clumsily
Answers questions slowly
Loses consciousness, even briefly
Shows mood, behavior or personality changes
Can’t recall events prior to hit or fall
Can’t recall events after hit or fall
SYMPTOMS REPORTED BY ATHLETES
Headache or “pressure” in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy or groggy
Concentration or memory problems
Confusion
Just not “feeling right” or “feeling down”
*Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical
neuropsychologist with concussion training
CONCUSSION DANGER SIGNS
Remember:
In rare cases, a dangerous blood clot
may form on the brain in a person with a
concussion and crowd the brain against
the skull. An athlete should receive
immediate medical attention after a
bump, blow or jolt to the head or body if
s/he exhibits any of the following danger
signs:
•
•
•
•
•
•
•
•
•
•
•
One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not
diminish, but gets worse
Weakness, numbness or decreased
coordination
Repeated vomiting or nausea
Slurred speech
Convulsions or seizures
Cannot recognize people or places
Becomes increasingly confused,
restless or agitated
Has unusual behavior
Loses consciousness (even a brief
loss of consciousness should be
taken seriously)
WHY SHOULD AN ATHLETE REPORT
HIS OR HER SYMPTOMS?
If an athlete has a concussion, his/her
brain needs time to heal. While an
athlete’s brain is still healing, s/he is
much more likely to have another
concussion. Repeat concussions can
increase the time it takes to recover. In
rare cases, repeat concussions in young
athletes can result in brain swelling or
permanent damage to their brains. They
can even be fatal.
Concussions affect people differently.
While most athletes with a concussion
recover quickly and fully, some will
have symptoms that last for days, or
even weeks. A more serious
concussion can last for months or
longer.
WHAT SHOULD YOU DO IF YOU
THINK YOUR ATHLETE HAS A
CONCUSSION?
If you suspect that an athlete has a
concussion, remove the athlete from
play and seek medical attention. Do not
try to judge the severity of the injury
yourself. Keep the athlete out of play the
day of the injury and until a health care
provider* says s/he is symptom-free and
it’s OK to return to play.
Rest is key to helping an athlete recover
from a concussion. Exercising or
activities that involve a lot of
concentration such as studying, working
on the computer or playing video games
may cause concussion symptoms to
reappear or get worse. After a
concussion, returning to sports and
school is a gradual process that should
be carefully managed and monitored by
a health care professional.
* Health care provider means a Tennessee
licensed medical doctor, osteopathic physician
or a clinical neuropsychologist with concussion
training.
Student-athlete & Parent/Legal Guardian Concussion Statement
Must be signed and returned to school or community youth athletic activity prior to
participation in practice or play.
Student-Athlete Name: _________________________________________________________
Parent/Legal Guardian Name(s): _________________________________________________
After reading the information sheet, I am aware of the following information:
StudentParent/Legal
Athlete
Guardian
initials
initials
A concussion is a brain injury which should be reported to my
parents, my coach(es) or a medical professional if one is available.
A concussion cannot be “seen.” Some symptoms might be present
right away. Other symptoms can show up hours or days after an
injury.
I will tell my parents, my coach and/or a medical professional about
my injuries and illnesses.
I will not return to play in a game or practice if a hit to my head or
body causes any concussion-related symptoms.
I will/my child will need written permission from a health care
provider* to return to play or practice after a concussion.
Most concussions take days or weeks to get better. A more serious
concussion can last for months or longer.
After a bump, blow or jolt to the head or body an athlete should
receive immediate medical attention if there are any danger signs
such as loss of consciousness, repeated vomiting or a headache
that gets worse.
After a concussion, the brain needs time to heal. I understand that I
am/my child is much more likely to have another concussion or
more serious brain injury if return to play or practice occurs before
the concussion symptoms go away.
Sometimes repeat concussion can cause serious and long-lasting
problems and even death.
I have read the concussion symptoms on the Concussion
Information Sheet.
N/A
N/A
* Health care provider means a Tennessee licensed medical doctor, osteopathic physician or a clinical
neuropsychologist with concussion training
______________________________________________
Signature of Student-Athlete
_______________________
Date
______________________________________________
Signature of Parent/Legal guardian
________________________
Date
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT
I have received a copy of the VUMC Notice of Privacy Practices. I understand that
VUMC has the right to change its Notice of Privacy Practices from time to time and that I
may contact VUMC at any time to obtain a current copy of the Notice of Privacy Practices.
Patient name (print) ________________________________________________________
Signature of Patient/ ________________________________________________________
Legal Representative
Relationship to Patient ______________________________________________________
Date __________________________
FOR OFFICE USE ONLY
PRINT PLEASE
I have attempted to obtain the patient’s signature on this form, but was not able to for the
following reason:
Date:
Please document the reasons you were
unable to obtain the signature.
Initials:
MC 2832 (3/2002)
Notice of Privacy Practices
Effective November 1, 2006
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ THIS NOTICE CAREFULLY.
If you have any questions about this Notice of Privacy Practices, please ask a member of the staff where
you receive health care services. You may also contact our Privacy Office at (615) 936-3594.
VANDERBILT UNIVERSITY MEDICAL CENTER (VUMC) IS COMMITTED TO YOUR PRIVACY
At Vanderbilt University Medical Center, we keep medical information about you to help us provide your
care and to meet legal requirements. We also understand that your medical information is private.
The law requires us to…
•
protect your medical information
•
give you this Notice
•
follow the terms of the Notice.
DEFINITION OF TERMS
In this document we will use words that will have the following meaning:
•
•
•
•
•
•
•
“Notice” is used to refer to this Notice of Privacy Practices
“VUMC” means Vanderbilt University Medical Center, together with its medical staff and
affiliated organizations listed at the end of this Notice
“we,” “our” or “us,” means one or more of the VUMC organizations and their individual licensed
providers and staff
“you” means the patient who is the subject of the medical information
“medical information” includes all paper and electronic records of your care that identify you
and relate to your past, present or future physical or mental health or condition including
information about payment and billing for your health care services
“use” means sharing or using your medical information within VUMC
“share” or “disclose” means to release, give access to, or provide your medical information to
someone outside VUMC.
HOW WE MAY USE AND SHARE INFORMATION ABOUT YOU
VUMC and its medical staff; employed healthcare professionals including physicians, nurses, care partners,
other employees; trainees and students; volunteers; and business associates follow the terms of this
Notice. VUMC uses electronic record systems to more efficiently and safely coordinate your care across
many individuals and locations. Physical and technical safeguards are used to protect the information in
these systems, and VUMC also uses policies and training to restrict use of your information to only those
who need it to do their job.
Doctors and other people who are not employed by VUMC may share information about you with VUMC
employees in order to provide your health care. These non-VUMC caregivers may also give you their
notices that describe their privacy practices for information they maintain outside of VUMC.
All of these hospitals, clinics, doctors, and other caregivers, programs and services may share your medical
information with each other for treatment, payment, and health care operations purposes. The general
ways that we can use and share your information are described below. While we cannot list every specific
use, we have given examples under each general category.
MC 2740 (10/2006)
Page 1 of 6
Notice of Privacy Practices
Treatment: We may use and share your medical information to provide you with health care services. For
example, a doctor treating you for a broken leg will need to know if you have diabetes because diabetes
may slow the healing process. The doctor may need to tell someone who works in food service that you
have diabetes so we can prepare the right meals for you. We may also share medical information about you
in order to provide you with items and services such as medicine, lab tests and x-rays, and to make
arrangements for transportation, home care, nursing homes, rehabilitation facilities, medical device or
equipment experts, or with community agencies and family members. This medical information may be
shared when needed in order to plan for your care after you leave VUMC.
Payment: We may use and share your information so that VUMC or other health care providers that have
provided services to you, such as an ambulance company, may bill and collect payment for those services.
For example, we may share your medical information with your health plan so your health plan will pay for
care you received at VUMC, or to obtain prior approval for a procedure, or to allow your health plan to review
your records to make sure they have paid the correct amount to VUMC. We may also share your information
with a collection agency when needed in order to collect an overdue payment.
Health Care Operations: We may use and share information about you for business tasks necessary to
operate VUMC. Whenever practical we may remove information that identifies you. For example we may use
or share your medical information:
•
•
•
•
•
•
•
•
•
•
•
•
to comply with laws and regulations
for health care training and education
to perform credentialing, licensure, certification, and accreditation functions
to improve our care and service
for our budgeting and planning
for legal services and compliance programs
to conduct audits
to maintain computer systems
to evaluate the performance of our staff in caring for you
to make decisions about additional services VUMC should offer
to do patient satisfaction surveys
to bill and collect payment.
When information is shared with outside parties (called “business associates”) who perform these tasks on
behalf of VUMC, the business associates are also required to protect and restrict use of your medical
information.
Contacting You about Appointments, Insurance and Other Matters: We may contact you by mail,
phone, or email about appointments, registration questions, insurance updates, billing or payment matters,
test results, to follow up about care received, or to ask about the quality of the services we have provided to
you. We may leave voice messages at the telephone number you give to us.
Treatment Alternatives or Health News and Services: We may use or share your information to inform
you about treatment options or health-related products or services that may interest you.
Fundraising Activities: We may use your name, address, phone number and the dates you received
services at VUMC to contact you in an effort to raise money to support VUMC. If we contact you, we will tell
you how to cancel these communications in the future.
Hospital Directory: If you are admitted to the hospital, your name, location in the hospital, general
condition such as “fair” or “stable” and your religion is included in our hospital patient directory at the
information desk. This helps your family, friends, and clergy visit you and learn your general condition. This
general information, except your religion, may be released to visitors or phone callers who ask for you by
name. Unless you tell us not to, your stated religion may be given to a member of the clergy, such as a priest
or rabbi, even if they don’t ask for you by name. You may ask to have your name removed from the directory
list and we will not release this general information even if you are asked for by name.
MC 2740 (10/2006)
Page 2 of 6
Notice of Privacy Practices
Family Members and Friends Involved in Your Care or Payment for Your Care: We may share
information about you with family members and friends who are involved in your care or payment for your
care. Whenever possible, we will allow you to tell us who you would like to be involved in your care.
However, in emergencies or other situations in which you are unable to tell us who to share information with,
we will use our best judgment and share only information that others need to know. We may also share
information about you with a public or private agency during a disaster so the agency can help contact your
family or friends about your location and tell them how you are doing.
Research: We may use and disclose medical information about you for the research we conduct in order to
improve public health and develop new knowledge. For example, a research project may compare the
health and recovery of patients who received one medicine for an illness to those who received a different
medicine for the same illness. We use and share your information for research only as allowed by federal
and state rules. Each research project is approved through a special process that balances the research
needs with the patient’s need for privacy. In most cases, if the research involves your care or the sharing of
your medical information, we will first explain to you how your information will be used and ask your consent
to use the information. We may access your medical information before the approval process to design the
research project and provide the information needed for approval. Health information used to prepare a
research project does not leave VUMC.
To Stop a Serious Threat to Health or Safety: When necessary to prevent a serious and urgent threat to
the health and safety of you or someone else, we may share your medical information. For example, threats
of harming another person may be reported to the police or other proper authorities.
Organ, Eye and Tissue Donation: We share medical information about organ, eye, or tissue donors and
about the patients who need those organs, eyes, or tissues with others involved in obtaining, storing and
transplanting organs, eyes, and tissues.
Military and Veterans: If you are a member of the armed forces, we may share your medical information
with the military as authorized or required by law. We may also release information about foreign military
personnel to the proper foreign military authority.
Workers' Compensation: We may share medical information about you with those who need it in order to
provide benefits for work-related injuries or illness.
Health Oversight Activities and Public Health Reporting: We may share information with health
oversight agencies for activities like audits, investigations, inspections, and review of requirements to obtain
a license. We may also share your medical information to file reports with state public health authorities,
agencies such as cancer registries, and the federal Food and Drug Administration.
Some examples of the reasons for these reports are:
•
•
•
•
•
•
•
to prevent or control disease and injuries
to report events such as births and deaths
to report child abuse or neglect of children, elders and dependent adults
to report reactions to medications or problems with products
to notify people of recalls of products they may be using
to notify a person who may have been exposed to a disease or may spread a disease
to notify the appropriate authority if we believe a patient has been the victim of abuse, neglect or
domestic violence.
Lawsuits and Disputes: We may share your medical information as directed by a court order, subpoena,
discovery request, warrant, summons or other lawful instructions from a court or public body when needed
for a legal or administrative proceeding.
Law Enforcement: We may release your medical information to a law enforcement official, as authorized or
required by law:
•
•
•
•
in response to a court order, subpoena, warrant, summons or similar process
to identify or locate a suspect, fugitive, material witness, or missing person
if you are suspected to be a victim of a crime, generally with your permission
about a death we believe may be the result of a crime
MC 2740 (10/2006)
Page 3 of 6
Notice of Privacy Practices
•
•
about criminal conduct at the hospital
in an emergency, to report a crime; the location of the crime or victims; or the identity,
description or location of the person who committed the crime.
We May Share Your Information With:
•
•
•
•
•
coroners, medical examiners and funeral directors so they can carry out their duties
federal officials for national security and intelligence activities
federal officials who provide protective services for the President and others such as foreign
heads of state, or to conduct special investigations
a correctional institution if you are an inmate
a law enforcement official if you are under the custody of the police or other law enforcement
official.
OTHER USES OF YOUR MEDICAL INFORMATION
We will not use or share your medical information for reasons other than those described above without your
written consent. For example, you may want us to give medical information to your employer or to your child’s
school. We will share your medical information for purposes like this only if you give your written approval.
You may revoke the approval, in writing, at any time, but we cannot take back any medical information that has
already been shared with your approval.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
The records we create and maintain using your medical information belong to VUMC, but you have the
following rights:
Right to Review and Get a Copy of Your Medical Information: You have the right to look at and get a
copy of your medical information, including billing records. You must first make your request in writing to
Medical Information Services at the address provided at the end of this Notice. We may charge a fee to
cover copying, mailing, and other costs and supplies used to respond to your request. We may deny your
request for certain information in very limited cases. If we deny your request, we will give you the reason for
the denial in writing. In some cases, you may request that the denial be reviewed by a licensed health care
professional chosen by VUMC.
Right to Ask for a Change of Your Medical Information: If you think our information about you is not
correct or not complete, you may ask us to correct the record by writing to Medical Information Services at
the address listed at the end of this Notice. Your written request must give the reason you ask for a
correction. We have 60 days to respond to your request. If we accept your request, we will tell you we
agree and add the correction. We cannot take anything out of the record. We can add new information to
complete or correct the existing information. With your help, we will notify others who have the incorrect or
incomplete medical information. If we deny your request, we will tell you in writing the reasons. If we deny
your request, you have the right to submit a written statement of 250 words or less that tells what you believe
is not correct or is missing. We will add your written statement to your records and include it whenever we
share the part of your medical record that your written statement relates to.
Right to Ask for an Accounting of Disclosures: You have the right to request a list of when your medical
information was shared without your written consent.
This list will not include uses or disclosures:
•
•
•
•
•
•
•
to carry out treatment, payment, or health care operations
to you or your personal representative
to those who request your information as listed in hospital directories
to your family members or friends who are involved in your care
as required or permitted by law as described above
as part of a limited data set with direct identifiers removed
released before April 14, 2003.
MC 2740 (10/2006)
Page 4 of 6
Notice of Privacy Practices
Any request for this list must be made in writing to the Privacy Office at the address listed at the end of this
Notice. Your request must state the time period for which you want the list. The time period may not be
longer than six years and may not begin before April 14, 2003. The first list you request within a 12-month
period will be free. We will charge you a fee for additional requests in that same period.
Right to Ask for Limits on the Use and Sharing of Your Medical Information: You have the right to ask
that we limit our use or sharing of information about you for treatment, payment or health care operations.
You also have the right to ask us to limit the medical information we disclose about you to someone who is
involved in your care or the payment for your care, like a family member or friend. For example, you could
ask that we not share information about a surgery you had. We reserve the right to accept or reject your
request. Generally, we will not accept restrictions for treatment, payment, or health care operations. We will
notify you if we do not agree to your request. If we do agree, our agreement must be in writing, and we will
comply with the restriction unless the information is needed to provide emergency treatment for you. We
are allowed to end the restriction if we tell you. If we end the restriction, it will only affect medical
information that was created or received after we notify you.
You must submit your request to restrict the use and sharing of your medical information in writing to the
Privacy Office at the address listed at the end of this Notice. In your request, you must tell us (1) what
information you want to limit (2) whether you want to limit our use, disclosure or both and (3) to whom you
want the limits to apply.
Right to Ask for Confidential Communications: You have the right to ask us to communicate with you in
a certain way or at a certain location. For example, you can ask that we contact you only at work or at a post
office box. You must make your request in writing to the Privacy Office at the address given at the end of
this Notice. You do not need to tell us the reason for your request. Your request must specify how or where
you wish to be contacted. You will also be required to tell us what address to send bills to for payment. We
will accept all reasonable requests. However, if we are unable to contact you using the requested ways or
locations, we may contact you using any information we have.
Right to Get a Paper Copy of This Notice: You have the right to get a paper copy of this Notice, even if
you have agreed to receive this Notice electronically. You may get a copy at any of our facilities, by
contacting the Privacy Office at the number below, or at the VUMC website, http://www.mc.vanderbilt.edu.
CHANGES TO THIS NOTICE
We have the right to change this Notice at any time. Any change could apply to medical information we
already have about you as well as any information we receive in the future. The effective date of this Notice is
on the first page. We will post a copy of the current Notice throughout VUMC and on the VUMC website,
http://www.mc.vanderbilt.edu.
HOW TO ASK A QUESTION OR REPORT A COMPLAINT
If you have questions about this Notice or want to talk about a problem without filing a formal complaint,
please contact the Privacy Office at 615-936-3594. If you believe your privacy rights have been violated, you
may file a written complaint with us. Please send it to the VUMC Privacy Official at the address listed below.
You may also file a complaint with VUMC Patient Affairs or the Secretary of the Department of Health and
Human Services at the addresses listed below.
You will not be treated differently for filing a complaint.
MC 2740 (10/2006)
Page 5 of 6
Notice of Privacy Practices
HOW TO CONTACT US
VUMC Privacy Office
1161 21st Avenue
D-2109 Medical Center North
Nashville, TN 37232-2655
(615) 936-3594
VUMC Medical
Information Services
1211 22nd Avenue
B-334 VUH
Nashville, TN 37232-7350
(615) 322-2062
VUMC Patient Affairs
1211 22nd Avenue
1101 VUH
Nashville, TN 37232-7566
(615) 322-6154
Office for Civil Rights
Region IV
[email protected]
DHHS
Atlanta Federal Center
61 Forsyth Street, S.W.
Suite 3B70
Atlanta, GA 30323
VUMC OPERATIONS AND AFFILIATES THAT WILL FOLLOW THE RULES OF THIS NOTICE
•
•
•
•
•
•
•
•
•
•
•
•
Vanderbilt University Hospital
Psychiatric Hospital at Vanderbilt
Monroe Carell Jr. Children’s Hospital at Vanderbilt
VUMC clinics and practices (a detailed list is available upon request)
VUMC Outpatient Pharmacies
Members of the VUMC Medical Staff while practicing at VUMC
Vanderbilt Medical Group
Vanderbilt School of Medicine
Vanderbilt School of Nursing
VUMC Administration, covered functions that involve the use or disclosure of PHI
Other Designated Health Care Components of Vanderbilt University.
Affiliated Covered Entities:
•
University Community Health Services (UCHS)
•
Vanderbilt Home Care Services
•
Vanderbilt Asthma Sinus Allergy Program (VASAP)
•
Vanderbilt Integrated Providers (VIP)
•
VIP MidSouth, LLC
•
Hillsboro Imaging (Vanderbilt Imaging)
•
Cool Springs Imaging (Williamson Imaging)
•
Vanderbilt-Ingram Cancer Center at Franklin
•
Gateway-Vanderbilt Cancer Treatment Center
MC 2740 (10/2006)
Page 6 of 6
Athlete/Parent/Guardian Sudden Cardiac Arrest Symptoms and Warning Signs
Information Sheet and Acknowledgement of Receipt and Review Form
What is sudden cardiac arrest?
Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly.
When this happens, blood stops flowing to the brain and other vital organs. SCA doesn’t just
happen to adults; it takes the lives of students, too. However, the causes of sudden cardiac
arrest in students and adults can be different. A youth athlete’s SCA will likely result from an
inherited condition, while an adult’s SCA may be caused by either inherited or lifestyle issues.
SCA is NOT a heart attack. A heart attack may cause SCA, but they are not the same. A heart
attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction in
the heart’s electrical system, causing the heart to suddenly stop beating.
How common is sudden cardiac arrest in the United States?
SCA is the #1 cause of death for adults in this country. There are about 300,000 cardiac arrests
outside hospitals each year. About 2,000 patients under 25 die of SCA each year. It is the #1
cause of death for student athletes.
Are there warning signs?
Although SCA happens unexpectedly, some people may have signs or symptoms, such as:
 fainting or seizures during exercise;
 unexplained shortness of breath;
 dizziness;
 extreme fatigue;
 chest pains; or
 racing heart.
These symptoms can be unclear in athletes, since people often confuse these warning signs
with physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and
treated.
What are the risks of practicing or playing after experiencing these symptoms?
There are risks associated with continuing to practice or play after experiencing these
symptoms. When the heart stops, so does the blood that flows to the brain and other vital
organs. Death or permanent brain damage can occur in just a few minutes. Most people who
experience SCA die from it.
Public Chapter 325 – the Sudden Cardiac Arrest Prevention Act
The act is intended to keep youth athletes safe while practicing or playing. The requirements of
the act are:

All youth athletes and their parents or guardians must read and sign this form. It must be
returned to the school before participation in any athletic activity. A new form must be
signed and returned each school year.
Adapted from PA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and
Acknowledgement of Receipt and Review Form. 7/2013

The immediate removal of any youth athlete who passes out or faints while participating
in an athletic activity, or who exhibits any of the following symptoms:
(i) Unexplained shortness of breath;
(ii) Chest pains;
(iii) Dizziness
(iv) Racing heart rate; or
(v) Extreme fatigue; and

Establish as policy that a youth athlete who has been removed from play shall not return
to the practice or competition during which the youth athlete experienced symptoms
consistent with sudden cardiac arrest

Before returning to practice or play in an athletic activity, the athlete must be evaluated
by a Tennessee licensed medical doctor or an osteopathic physician. Clearance to full or
graduated return to practice or play must be in writing.
I have reviewed and understand the symptoms and warning signs of SCA.
Signature of Student-Athlete
Print Student-Athlete’s Name Date
_____________________________
Signature of Parent/Guardian
_________________________ __________
Print Parent/Guardian’s Name Date
Consent: ImPACT™ and BESS Testing
Vanderbilt Sports Medicine
This section is about testing:

You are having an Immediate Post-Concussion Assessment and Cognitive Test (ImPACT™) and a
Balance Error Scoring System (BESS) test.

The person talking with you about the testing and your options is:
____________________________________________________________________________

The person in charge of doing and overseeing the testing is:
____________________________________________________________________________

Some tests have risks. Because BESS is a balance test, there is a small risk of falling.
I understand that:
o These tests are baseline tests only. This means that they will only be used to get a “normal”
baseline in case I need to be tested for a future concussion. Vanderbilt may use results from
this testing for research purposes. Before any results from my testing are used for research,
any personal information that could link me to these results will be completely removed.
o If I have a concussion during the athletic season, and if I have ImPACT™ or BESS testing,
Vanderbilt may use results from this testing for research purposes. Before any results from
my testing are used for research, any personal information that could link me to these
results will be completely removed.
o I am only agreeing to be tested today and not to any future tests. Vanderbilt is not obligated
to give me any future ImPACT™ or BESS tests.
o My insurance cannot and will not be billed for the ImPACT™ or BESS test. I must pay the full
cost of the ImPACT™ and BESS tests in advance.
o The results of these tests are privileged and confidential. Except as permitted by law, the
results will only be shared with my doctor and those involved in my care at Vanderbilt. They
will only be shared with others if I allow this in writing.
This section is for your permission:




I allow Vanderbilt University Medical Center (VUMC) and staff to test me.
The staff may include: doctors, nurses, residents and students. This staff may help to do important
parts of my testing. The staff may also include technicians, assistants, or others. The doctor may
ask others who do not work at VUMC to be in the room to support the use of the equipment.
I know what I am having done. I know the reason I am having it done. I know the risks and
benefits of it. I know the other choices that I have.
Results of testing will be given to me.
MC 9332 (08/2012)
Page 1 of 2
Consent: ImPACT™ and BESS Testing
Vanderbilt Sports Medicine


I know that my results are not certain.
If any Vanderbilt employee is exposed to my blood or body fluids, I will allow my blood to be tested.
This section is to give permission:
Patient/person legally able to sign for patient: I have read and understand this information. My questions
are answered.
Sign name: _______________________________________________________________________
[Person legally able to sign may sign if patient is not able or if patient is a minor]
Print name: ____________________________________________________ Relation: ____________
Date: ____________ Time: ______________
Telephone consent given by: ______________________________________ Relation: ____________
Date: ____________ Time: ______________
Witness to sign name: ___________________________________________ Title: _______________
[Needed for telephone consents]
Date: ____________ Time: ______________
The patient or person legally able to sign for the patient is able to tell me in his/her own words about the
testing. This includes the part of the body involved, risks, benefits, and options.
Doctor or person doing the procedure to sign name: __________________________________________
Print name: ____________________________ Date: __________________ Time: __________________
Contact information for the interpreter, if one was used:
Name: ________________________________ Language: _________________ Number: ____________
MC 9332 (08/2012)
Page 2 of 2