| Emergency Contact Information |
| Student-Athlete Information |
First Name
|
Last Name
|
Gender
|
Sport
|
Date of Birth
|
Cell Number
|
Chadron Address
|
| Primary Emergency Contact |
First Name
|
Last Name
|
Home Telephone
|
Work Telephone
|
Cell Number
|
Email Address
|
Relationship to Student Athlete
|
| Secondary Emergency Contact (Optional) |
First Name
|
Last Name
|
Home Telephone
|
Work Telephone
|
Cell Number
|
Email Address
|
Relationship to Student Athlete
|
| Health Insurance Information |
| Primary Policy |
Policy Holder’s Name
|
Relationship to Athlete
|
Insurance Company
|
Policy Number
|
ID Number
|
Group Number
|
Effective Date of Policy
|
Expiration Date of Policy
|
Is this an HMO Policy?
|
Is this a PPO Policy?
|
| Address for Insurance Company's Claim Office |
Address
|
City
|
State
|
Zip Code
|
Phone Number
|
Fax Number
|
| Secondary Policy (Optional) |
Policy Holder’s Name
|
Relationship to Athlete
|
Insurance Company
|
Policy Number
|
ID Number
|
Group Number
|
Effective Date of Policy
|
Expiration Date of Policy
|
Is this an HMO Policy?
|
Is this a PPO Policy?
|
| Address for Insurance Company's Claim Office |
Address
|
City
|
State
|
Zip Code
|
Phone Number
|
Fax Number
|
| Medical History |
| Diseases and Illnesses |
Have you ever experienced an epileptic seizure or been informed that you may have epilepsy?
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Have you ever been diagnosed as having high blood pressure?
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Have you ever experienced chest pain during or after exercise?
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Have you ever been told you have a heart murmur, heart disease or heart trouble?
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Have you ever had hepatitis?
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Which Type
|
When
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Have you been treated for any infections disease(s) in the past 12 months?
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Do you, or an immediate family member have a systemic (diabetes, etc) disease?
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Do you, or an immediate family member have a progressive disease (multiple sclerosis) or cancer?
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Have you ever had an ulcer?
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Have you ever had tuberculosis?
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Have you ever had appendicitis or an appendectomy?
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Have you ever had arthritis?
|
Have you ever had a hernia or rupture?
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Are you allergic to bee stings or insect bites?
|
| Head and Neck |
Have you ever had (a) head injury/injuries or concussion(s)?
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Have you ever had to go to a hospital, emergency room or clinic for a head or neck injury?
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Have you ever been knocked out or unconscious?
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Have you ever had a “stinger” or a “burner”?
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Have you ever had whiplash, a pinched nerve, or severe headaches?
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Do you wear a mouthpiece during athletic participation?
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Do you wear a dental appliance (other than a mouth guard) when you participate in athletics?
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Have you ever had a problem with your vision?
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Do you wear glasses, contacts, or protective eyewear?
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Do you have loss of sight in either eye?
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If yes, which one?
|
| Bone and Joint |
Have you ever been unable to participate in athletics due to a shoulder injury?
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Have you ever been advised to have surgery to correct a shoulder condition?
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If yes, has the surgery been performed?
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Give date:
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Have you ever sprained, dislocated, had repeated swelling, and/or repeated pain in any joints/bones?
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Do you have any pins, screws, wires, plates or other hardware implanted in you as a result of a surgical repair?
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Do you use any protective equipment (braces, neck roll, etc) while participating in athletics?
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Have you ever had a fracture?
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Have you ever injured your neck, back or vertebral disks?
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Have you ever had surgery to correct a bone or joint problem?
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Has a medical practitioner given you any special instructions or placed any restrictions on you?
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Have you ever been told that you injured the ligaments/cartilage in either knee joint?
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Have you ever been advised to have surgery to a knee to correct a condition?
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If yes, has the surgery been performed?
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Please provide dates:
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Have you had a severe sprain of either ankle during the past two years?
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Have you ever had a bone graft or spinal fusion?
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Site:
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Dates\:
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Have you ever had synovial fluid (water in the knee or elbow) removed?
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Indicate Date:
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| General Medical |
Are you currently under a doctor’s care?
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Do you have any other medical conditions not mentioned above?
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Have you had any heat-related illnesses (heat cramps, fainting, heat exhaustion, heat stroke)?
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Are you currently taking any medications regularly (birth control, pain killers, insulin, etc.) either prescribed by a physician or over the counter?
|
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Are your immunizations up to date?
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Do you have any problems with or are you missing any paired organs (kidneys, eyes, etc)?
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Have you ever been diagnosed with a kidney or bladder infection?
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Have you had any operations during the last five years?
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Anatomical Site
|
Date
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Have you been advised by a medical doctor not to participate in sports?
|
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Have you ever had an eating disorder?
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Have you ever been hospitalized?
|
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Have you ever had a problem with dehydration?
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| Females Only |
Do you experience any problems with menstruation?
|
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Do you have irregular menstrual cycles?
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| Once you submit this form you will be directed to a new page with printable forms that must be filled out and returned to the Athletics Office by fax at 308.432.6493 or scan the completed form and attach it to an email to mmiskimins@csc.edu. |
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