Returning Student Athlete Medical History Questionnaire

Returning Student Athlete
 Medical History Questionnaire
This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The NCAA’s policies recommend that all student-athletes have a qualifying medical evaluation upon entrance into an institution’s intercollegiate athletic program, and an annual “health status” review. UVM supports this NCAA policy. Further medical evaluations may be required for specific matters. Please read all questions carefully and respond by selecting the appropriate response. It is recommended that you obtain a copy of your insurance card for reference while completing this questionnaire.

Demographic Information
Gender:




Your Sport(s):

Academic Year this Questionnaire Applies To:

Your Year in School:



Your Blood Type:



Addresses

Your Permanent Address:
Your Campus/Local Address:

On Campus:



















Off Campus:


Contact Information

Parents or Legal Guardians:
Your Family Doctor (Primary Care Provider):
Your Health Insurance
Type of Insurance Plan (choose):

Medical Questions


 Please answer all applicable questions. Please explain any YES responses and provide a date in the space provided.
Have you been hospitalized or had a major illness within the last year?


Are you currently ill in any way? Are you under a physician’s care?


Have you had a heat related illness within the last year?


Have you had a major injury (i.e. Concussion, broken bone, sprained ligament, etc.) within the last year?


Do you currently have any incompletely healed injuries?


Have you experienced a racing/irregular heart beat, dizziness, or chest pain while exercising within the last year?


Are you currently taking any medication? (Inhaler, Birth Control, Prescription, Advil, Sudafed, etc)?



Are you allergic to any medications, foods, insect bites or other?



Have you been treated for any infectious disease(s) (i.e. hepatitis, meningitis, tuberculosis, etc.) within the last year?


Do you regularly use nutritional supplements?


Would you like our sports nutritionist to contact you for consultation or advice?


Do you now, or have you ever-used illegal drugs?


Would you like a counselor to contact you about drugs or alcohol?


Have you ever-used anabolic steroids or other performance-enhancing agents?


Have you been in a car or work accident within the last year?


Do you know of, or do you believe there is, any health reason why you should not participate in the University’s Intercollegiate Athletic Program at this time?


Females Only

Have you had any change in your gynecological history within the last year (i.e. cysts, absent or irregular periods, etc.)?



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Agreement to Participate in University of Vermont Intercollegiate Athletics

I am aware that trying out for and playing or practicing in any sport can be a dangerous activity involving MANY RISKS OF INJURY. I understand the dangers and risks of trying out for and playing and practicing in the above sports include, but are not limited to death; serious neck and spinal injuries which may result in complete or partial paralysis or brain damage; serious injury to virtually all bones, joints, ligaments, muscles, tendons and other elements of the muscular-skeletal system; and serious injury or impairment to other parts of my body, general health and well-being.

Because of the dangers of participating in any of the above sports, I recognize the importance of following the coach’s instructions regarding playing techniques, training, rules of the sport and other team rules, and of following such instructions.

In consideration of UVM permitting me to try out for, practice, play or otherwise participate in the above listed intercollegiate sports and to engage in all activities related to the team, including, but not limited to practicing, playing and travelling, I hereby voluntarily assume all risks associated with participation and agree to hold harmless the University of Vermont, its agents, officers and employees including, but not limited to the athletics staff of the University of Vermont from any and all liability, claims, causes of action or demands of any kind and any nature whatsoever which may arise by or in conjunction with my participation in any activities related to the University of Vermont Intercollegiate Athletics Program except in the event of their gross negligence. The terms of this Agreement shall serve as a release and assumption of risk for my heirs, estate, executor, administrators, assignees and all members of my family.

To the best of my knowledge, I am in good health and suffer no disability or condition which renders my participation in the sport(s) or other athletics activity medically inadvisable, or otherwise limits my ability to participate in such sport(s) or athletics activity without restriction.

I hereby authorize the coach or other appropriate University of Vermont personnel to obtain in my behalf first aid, emergency medical care, or if necessary admission to an accredited hospital, when such care is necessary for the treatment of any injuries I may sustain while participating in any activity associated with University of Vermont intercollegiate sports, including practices, competition and travel. I also hereby consent to the administration of emergency medical treatment in the event I am unable subsequent to such injury to give such consent as otherwise necessary.

Please read the above over again carefully before clicking below. Your click below to submit constitutes your legal signature and binding agreement to the terms set forth above.

Medical Authorization

I hereby grant permission to the University of Vermont Athletic Medicine staff and Emergency Medical Personnel to proceed with any treatment, medical or surgical care that they deem necessary to my health and well-being. In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to notify my parent/guardian or the designated emergency contact in the most expeditious manner possible. If said physician is unable to communicate with my parent/guardian or designated emergency contact, the treatment deemed necessary for my best interest may be given.

I also hereby authorize the Athletic Trainers at the University of Vermont who are under the direction and guidance of the University team physician, to render me any preventive, first-aid, rehabilitative, or emergency treatment that they deem reasonably necessary to my health and well-being.



Sharing of Information

I understand that the University of Vermont Center for Health & Wellbeing (CHWB) Athletic Trainers, Team Physicians, and clinical staff may share amongst themselves for the purpose of treatment information concerning health issues or injury relative to my past, present, or future participation in athletics at UVM. Also, the above will provide appropriate medical information to insurance companies pertaining to the student-athlete as needed. CHWB providers may discuss my medical information with my coaching staff(s) only as it pertains to my participation in my sport(s).


Authorization for Release of Information

I authorize the University of Vermont Center for Health & Wellbeing (CHWB) Athletic Trainers and/or Team Physicians to provide medical information to the UVM Athletic Communications Office pertaining to injuries and/or illnesses that may occur to me during my participation as a student athlete here at UVM that affect my performance or ability to participate in intercollegiate athletics. I understand that Athletic Communications may share this information with the media and/or the public. I may rescind this authorization at any time by notifying the UVM Athletic Medicine Department and the UVM Athletic Communications Office in writing.


Shared Responsibility for Sport Safety

Participation in sports requires an acceptance of risk of injury. Your decision to participate in athletics indicates your acceptance of this risk. In order to minimize this risk as a participant, you must be aware of and abide by certain procedures, safety rules, and guidelines. Sound conditioning and training programs are designed to help in the prevention of injury; rehabilitation programs are designed to enable recovery and return to participation safely. Your responsibility to these programs is as important as your responsibility to learning and using proper skills, techniques, and the strategies of your sport. Any improper use or abuse of your equipment could result in injury to you, a teammate, or an opponent. Improper use of your equipment or technique may result in serious head and neck injuries, paralysis, internal injury, and death. Athletes rightfully assume that those responsible for the conduct of sports will not intentionally inflict injury upon them, but acknowledge that unintentional injuries, including serious head and neck injuries, paralysis, internal injury, death, sprains, strains, fractures and contusions, can certainly happen while participating in or training for athletic events. Periodic analyses of injury patterns lead to refinements in the rules and other safety decisions, but safety cannot be legislated solely through a rule book and equipment standards. The responsibility for sport safety must be shared by all involved, and compliance with the rules means respect on everyone's part for the intent, spirit, and purpose of the rules or guidelines.

I. I agree to allow the Athletic Medicine Staff to evaluate, treat and care for any injury or illness, which may occur to me.

II. I agree to allow the Athletic Medicine Staff to communicate to my coaching staff pertaining to their care.

III. I understand that I must refrain from practice or play while ill or injured, whether or not receiving medical treatment, and maintain medical treatment until I am discharged from treatment or given permission by the Athletic Medicine staff to restart participation while continuing treatment.

IV. I understand that having passed the medical qualifying evaluation does not necessarily mean that I am physically qualified to engage in athletics, but only that the evaluation did not find a medical reason to disqualify me at the time of said evaluation.

V. I agree to report to the Athletic Medicine Staff:

A. All injuries and illness sustained

B. All medications taken for whatever reason.


The Fine Print (Read Carefully!)


 Please read the above over again carefully before clicking below. Your click to submit constitutes your legal signature and binding agreement to the terms set forth above.
By selecting "Submit Questionnaire" you:
A. Certify that the answers to the previous questions are complete, correct, and truthful to the best of your knowledge.
B. Fully realize that the University of Vermont cannot be held responsible for any previous medical condition(s) that you might have.
C. Fully realize that misrepresentation of information could have serious medical implications leading to injury and, in extreme circumstances, death.
Misrepresenting one’s health or medical history may be cause for disqualification from Intercollegiate Athletics at the University of Vermont.
 By submitting this I agree to the terms set forth above.

Brought to you by UVM's Center for Health & Wellbeing