Lock Haven University of Pennsylvania
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Athletic Training
Phone: (570) 484-2878
Fax: (570) 484-2220
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Email: athletictraining@lhup.edu
Medical Exception ADHD / ADD
The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in
competition. Some legitimate medications contain NCAA banned substances, and student-athletes may need to use
these medicines to support their academics and their general health. The NCAA has a procedure to review and
approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions
Procedure. The following guidelines will help ensure adequate medical records are on file for student-athletes
diagnosed with ADHD in order to request an exception in the event a student-athlete tests positive during NCAA
Drug Testing.
Today’s Date: _________
Student-Athlete’s Name_____________________ Sport ____________Date of Birth ___/___/____
Dear Provider: Your patient is a student-athlete participating in intercollegiate athletics. The NCAA
bans the use of some stimulant medications and requires that the following documentation is submitted to support a
request for a medical exception in the case of a positive drug test for such use. For additional information, visit the NCAA
Health & Safety website:
http://www.ncaa.org/wps/ncaa?ContentID=481
Diagnosis: __________________________
Date of Initial Clinical Evaluation and Diagnosis: ___________________
Current Medication(s) * and Dosage:
__________________________________________________________________
*NCAA requires that non-banned medications be considered (if not considered please comment below)
____________________________________________________________________________________
____________________________________________________________________________________
Monitored blood pressure ______________ Pulse __________ Date ________________
Lab Work (if applicable) __________________________________________________________
Patient will follow-up in (circle one): 1 month 3 months 6 months 12 months other________
Required ADHD Evaluation Components:
___ Comprehensive clinical evaluation (using DSM-IV criteria) ATTACH
___ A physical exam
___ Adult ADHD Rating Scale Used: ___________________________________________ ATTACH
(e.g., Adult ADHD Self Report Scale (ASRS), CONNER’s Adult ADHD Report Scale (CAARS)
Copies of the evaluation components above should be submitted with this completed form for the athlete’s college
medical record / NCAA. Please feel free to also attach any clinical notes that may help clarify your patient/our athlete’s
diagnosis of ADHD/ADD and the need for stimulant medications.
If applicable please submit any additional ADHD evaluation components: (e.g. reporting of ADHD symptoms by other
significant individual(s), other psychological testing, previous documentation of ADHD diagnosis, or other components).
Additional notes:
Signature: ___________________________ Specialty: _________________________________
Physician/Provider (Printed):__________________________________ Date: ____/____/____
Office Address: ____________________________________ Phone #:____________________
Lock Haven, PA 17745
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www.lhup.edu/athletictraining