ATHLETIC TRAINING MEDICAL HEALTH RECORD
Department of Athletic Training
Marist College
Page 1.
Name __________________________________S.S. # __________________ Date __________
(Last)
(First)
(M.)
Local Address ___________________________________________ Home Phone _____________
(Street)
(City)
(State)
Name and address of person to contact in an emergency: ___________________________________
Name
_________________________________________________________________ _____________
Street
City
State
Zip
Phone Number
Name and address of family physician _________________________________________________
Name
_______________________________________________________________________
____________
Street
City
State
Zip
Phone Number
VACCINATIONS/TESTS
1. Please indicate below if and when you have had the following vaccinations/tests.
Month/Year
1. PPD (TB skin test)
2. Hepatitis B
NOTE:
It is suggested that you discuss with your healthcare provider about receiving the
meningiococcal meningitis vaccine. You must comply with the State of Illinois
immunization requirements: tetanus, diphtheria, measles, mumps and polio for
entrance to SIUC.
MEDICAL EVALUATION
I have evaluated the medical status of this individual and there are ( ) / are no ( ) medical
conditions that would place this individual at risk if he/she enters into the Athletic Training
Education Program. This individual has received vaccinations and tests as indicated above.
Comments:
________________________________________________________________________
_
________________________________________________________________________
_
________________________________________________________________________
_
________________________________________________________________________
_
(Print) Physicians Name, Address, Phone Number
____________________________________________
(Physician’s Signature)
__________
(Date)
(To be completed by the student)
To my knowledge I have no medical condition that would be aggravated by my presence
in the Athletic Training Education Program nor do I have a malady that would be
deleterious to the patients I treat. I understand that it is my responsibility to return a
completed copy of this form to: Chair/Program Director of Athletic Training, School of
Science, Marist College, Poughkeepsie, NY 12601 for their records prior to beginning
any clinical experiences. My signature below is my approval to give me a copy of this
form.
_____________________________________________ ______________________
(Student Signature)
(Date)
Original to patient record
Copy of Medical Evaluation to the patient for return to: Chair/Program Director of
Athletic Training, School of Science, Marist College, Poughkeepsie, NY 12601
PERSONAL HEALTH HISTORY AND PHYSICAL EXAM
Page 2.
PERSONAL HISTORY and PHYSICAL EXAMINATION:
Check only if they apply to you. Explain details or abnormal results on the back of this form.
Asthma – Allergy ___
Backache or Injury ___
Diabetes ___
Fainting Spells or Blackouts ___
Heart Trouble ___
Hepatitis ___
High Blood Pressure ___
Immunosuppressed ___
Migraine Headaches ___
Seizures or Convulsions ___
Skeletal Deformity ___
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Prosthesis & Sensory Aids, such as:
Glasses ___
Contact Lenses ___
Artificial Limb ___
Hearing Aid ___
Lift or assist in lifting patients using proper body mechanics.
Ability to carry up to 100 lbs. with assistance.
See, hear, and respond quickly to patients in emergency situations.
Communicate with patients and other health care professionals.
Understand requisitions and other records necessary for proper patient care.
Ability to move quickly to avoid personal injury.
Ability to transport injured patients/athletes to health care facilities.
Ability to stand while covering a practice or contest for a 2-3 hour duration.
Ability to demonstrate weight training and rehabilitation exercises.
Ability to provide manual resistance to the patient/athlete for rehabilitation.
Ability to tape and wrap injured body parts.
Physical ability to assess injured body parts.
Stamina to work in stressful situations.
Perseverance, diligence, commitment to completion ATEP.
List all prescription and/or non-prescription medication, shot or drug currently in use. List the purpose for
the use of each.
Please use this space to comment or explain any abnormal history or physical findings and to indicate how
this will affect the ability to provide patient care or affect professional behavior. Also, please explain which
technical ability (ies) the student has difficulty performing.
________________________________________________
Physician’s Signature
____________
Date
Waiver:
I, __________________________________ acknowledge the accuracy of this medical history.
Student’s Name