University of North Carolina Wilmington: Screening Examination for New Athletes
Name _________________________________ Sport: □ M □ F ______________________
Age _____
Class: Fr
Date _____/______/____
Date of birth _____/_______/________ ID# ________________________________
So
Jr
Sr
Home or cell phone number (
M
) _______________________
Please answer the following questions. State “none” or “NA” if not applicable:
Current medications -- please list all prescription and over-the-counter:
Allergies to medications:
Current medical conditions/injuries being treated:
Past hospitalizations or surgeries? (year, reason):
Do you currently take or plan to take supplements such as protein, creatine, or others? If yes, please list:
Do you smoke or use tobacco products?
Have you ever had any of the following injuries or conditions?
Please explain any “yes” answers in the space to the right
Heat related illness/severe cramps/passing out during exercise in hot weather
Lightheadedness/dizziness/fainting or chest pain with exercise
Severe headaches or headaches brought on by exercise
Recent problems keeping up with teammates in sports
Absence/loss of a paired organ (eye, kidney, testicle)
Diabetes
High blood pressure
Kidney disease
Epilepsy /seizures
Anorexia/bulimia
Bleeding problems (free bleeding, hemophilia)
Sickle cell anemia/sickle cell trait
Hernia
Been told you have a heart murmur or heart problem or rheumatic fever
Been told you have Marfan’s Syndrome
Whole body/severe/shock allergic reaction to bee stings, food, other
Have you used/do you use performance enhancing substances or drugs?
Has a doctor ever advised you not to participate in athletics?
Female athletes only:
Are your menstrual periods regular and monthly?
When did you last menstrual period begin?
What was the longest time between your periods in the last year?
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F
List date/details
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
N
Vision History
Explain
Do you wear glasses during sports participation?
Do you wear contacts during sports participation?
Do you have any type of eye trouble?
Y
Y
Y
N
N
N
Do you have any chipped, loose, or missing teeth?
Do you wear a dental appliance?
Y
Y
N
N
Family History
Have any of the following conditions been present in your immediate family?
Congenital (born with) heart disease
Marfan’s syndrome
Sickle cell anemia or trait
Death while exercising
Died aged <50 years unexpectedly (sudden death)
Bleeding problems (blood clots in legs/lungs, hemophilia)
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Injury History
Have you had an injury of:
Head (concussion, LOC, surgery, hospitalization)
Eye (contusion, finger to eye, loss of vision)
Ear
Nose/Face (fracture, laceration)
Neck (strain, fracture, “stinger” or “burner”)
Shoulder (dislocation, separation, rotator cuff, tendonitis)
Arm/elbow (sprain, fracture, dislocation, tendonitis)
Wrist/hand (sprain, fracture, dislocation, tendonitis)
Fingers (sprain, fracture, dislocation)
Chest (rib fracture, lung, heart)
Abdomen (spleen, liver)
Kidney (contusion)
Groin (strain, pull)
Genitals (contusion, pain)
Back (strain, chronic pain, slipped disc, fracture)
Hip/thigh (sprain, strain, fracture, calcium deposit)
Knee (sprain, fracture, bursitis, tendonitis)
Lower leg (strain, fracture, shin splints)
Ankle (sprain, fracture, tendonitis)
Foot (sprain, fracture, tendonitis)
Toes (sprain, fracture, dislocation)
Do you wear any type of brace, tape, or special padding for play?
Have you had an illness/injury in the last 12 months not listed above?
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Dental History
(which ones?)
(what type?)
side
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
date
R L
R L
R
R
R
R
R
L
L
L
L
L
R L
R L
R L
R
R
R
R
R
R
L
L
L
L
L
L
Do you have any health concerns about participating in UNCW intercollegiate athletics?
Yes
No
If yes, please elaborate:
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description
Acknowledgement of Responsibility and Risks Statement:
I am choosing to participate in intercollegiate athletics. I take personal responsibility for this decision.
I understand that participation in sport activity involves the potential for injury, which is inherent in all
sports. I acknowledge that even with the best coaching, guidance of athletic trainers, use of protective
equipment, and observance of rules, injuries are still a possibility. On rare occasions, these injuries can be so
severe as to result in total disability, paralysis or even death.
I understand that I must refrain from practice or play while ill or injured, whether or not receiving medical
treatment. I will make every effort to follow the directions of the athletic training staff and physicians
providing treatment to me for any injuries or illnesses. I understand that I may not resume competition or cease
necessary treatment for my injuries or illnesses until I am released to do so by a UNCW Team Physician and/or
Athletic Trainer. I authorize the Athletic Training Staff to contact the below signed parent/guardian if I
am not fulfilling my responsibility to attend necessary treatment appointments as designated by a UNCW
Team Physician and/or Athletic Trainer, in order to inform the parent/guardian of this information.
I understand that this screening examination is not an all-encompassing process to detect and treat my
overall health. Rather, the screening questions/exam attempt to identify conditions which need further
evaluation and consideration before I can safely participate in intercollegiate sports. However, this screening
process is not able to detect all conditions which might put me at risk of injury or sudden death.
I certify that my answers in the medical history form on the prior pages are correct and accurate to the best
of my knowledge.
ATHLETE AND PARENT/GUARDIAN MUST BOTH SIGN BELOW:
Athlete’s Signature:__________________________________________Date : ______/______/_______
Parent/Guardian Signature:________________________________________Date : _____/______/______
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Name
______________
Physical Examination
Vital Signs
Ht_____ft._____in.
Wt___________ lbs.
BP _______/______
Pulse _________
Comments if abnormal:
Eye Examination
Vision R 20 /______/_____
□ PEERL
□ EOMI
L 20 /______/_____ Corrected? Y N
Contact Lenses? Y N
Comments if abnormal :
General Examination
Normal
Abnl
Comments/details
head
ears
mouth/ throat
neck
lungs
abdomen
genital (males only)
Cardiovascular Examination
Yes
No
Remarks
Blood pressure abnormal?
(systolic >140 and diastolic >90)
Cardiac auscultation:
Murmur left sternal border standing?
Other murmur?
Other abnormal sounds?
Signs of Marfan’s Syndrome (tall, higharched palate, long arms compared with
height, long/slender fingers, hyperflexible joints, concave chest,
nearsighted)?
Comments:
___________________________________________
Examining Provider Signature
Name
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_______
Musculoskeletal Examination
Appearance/ROM
Normal
Abnl/Laxity
Findings/comments
Cervical spine/neck
R shoulder
L shoulder
R elbow
L elbow
R wrist/ hand
L wrist/ hand
R hip
L hip
R knee
L knee
R ankle
L ankle
Lumbar/thoracic spine
hamstring flexibility
Heel/Toe/Duck walk
_________________________________________ Orthopedic evaluation recommended by history or exam? Y
N
Examiner Signature
_____________________________________________
Orthopedic Provider Signature
Provider’s Recommendation:
_____ Approved for intercollegiate athletics at UNCW with no restrictions
_____ Approved for athletics at UNCW with the following recommendations/restrictions (explain):
_____ Approved for intercollegiate athletics at UNCW until
/
___________________________________________
Physician’s Signature
/
/
, pending:
/ 200
Date
Follow-up completed ______/_____/________
___________ Provider initials
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