Pre-Participation Physical Examination Packet for Club
Sport Athletes checklist:

Fill out pages 2-15in BLACK INK
 Student-Athlete signatures where applicable
 Parent signatures where applicable
 Legible copies of insurance card
 Complete explanations “yes” answers including dates of injury, illness,
and/or surgery

Pages 14-15 to be filled out by Physician

Athletes that participate in Hockey, Men’s Rugby, Women’s Rugby, and Cheerleading
please read page 2 for detailed instructions for concussion baseline testing instructions.
Please note Page 2 needs to be signed and returned.

Further medical documentation necessary if you have:



Newly diagnosed heart murmur or other cardiac abnormality (within 1 year)
Absence of paired organ
Major Orthopedic Injuries/surgeries or illnesses requiring significant medical
attention

Make a copy of these forms for your personal records

When packet is COMPLETE, mail to:
Sports Medicine Office
The Catholic University of America
Room 108, DuFour Athletic Center
620 Michigan Ave., NE
Washington, DC 20064
It is essential that these forms are completed and returned to the Athletic Training Room no later
than Thursday, July 1, 2011. If the necessary forms are not on file, or information is
incomplete, YOU WILL NOT BE ABLE TO BEGIN PRACTICE. THERE WILL BE NO
EXCEPTIONS.
PLEASE NOTE THERE WILL BE A 48 HOUR PROCESSING PERIOD ON ALL
PHYSICAL FORMS.
**The athletic department does NOT need your immunization records. Please send
them directly to Student Health Services.
**Submitting your primary insurance information is for Athletic Training Department use only. It is IN NO WAY a substitute for the
waiver of the CUA Medical Plan. That is to be done through Cardinal Students.**
Thank you,
CUA Athletic Training Staff
CUA Pre-participation Physical Exam Packet
Page 1 of 15
Participation will NOT be allowed until this packet is completed.
ImPACT CONCUSSION MANAGEMENT BASELINE TESTING
1. WHAT IS ImPACT?
a. ImPACT is a concussion management test that establishes normal
cognitive brain function, when taken prior to a concussion or after prior
concussion symptoms have fully resolved. The baseline test will be used
in comparison with a post concussion test to determine if normal cognitive
brain function has returned. The results of the test will be used in
conjunction with other return to play concussion guidelines to ensure the
safe return of our student athletes to sport participation.
b. This is not a graded test. The purpose is to determine your normal brain
function.
2. COMPUTER REQUIREMENTS TO TAKE THE TEST
a. Make sure you are using Internet Explorer 6.0 and above or Firefox 1.5 or
above and Safari for the MAC running OSX 10.2 and above.
b. You must have Macromedia FLASH PLAYER 8.0 or newer installed.
You can download FLASH PLAYER at www.adobe.com
c. If you have a pop up blocker installed you must turn it off for the
duration of the test.
d. Close all other programs on your computer before taking the test.
e. You need a broadband internet connection
f. The computer you use must have a mouse
3. TIME REQUIREMENT TO TAKE THE TEST
a. The test will take approximately 25 to 30 minutes to complete. The
system allows up to 45 minutes to take the test.
b. Give yourself enough time to complete the test and make certain that
during this time that you will have NO distractions and will be able to
concentrate.
4. ACCESSING THE TEST
a. Please use the following link for baseline testing:
http://www.impacttestonline.com/colleges
b. Select District of Columbia in the Please select your organization drop
down box.
c. Insert the following customer ID# C6F6RTEQEN
d. Follow the directions on the website and choose the appropriate answers
to demographic questions.
e. The examination will include instructions that some information is to be
entered by the examination supervisors; however, all information should
be answered by the student-athlete.
Once you have completed the ImPACT baseline test sign and date below:
Athlete’s Signature ________________________________________Date_______
CUA Pre-participation Physical Exam Packet
Page 2 of 15
Date received of completed 2011-12
packet (office use only)
Participation will NOT be allowed until this packet is completed.
PERSONAL INFORMATION
Note: Failure to complete all blanks will result in claims processing delays. If information is not
applicable, please indicate reason. (i.e. deceased, divorced, unknown)
ATHLETE INFORMATION:
Name of Athlete______________________________
Social Security #______________________________
Date of Birth_________________________________
Class: Fr Soph Jr Sr 5 th Other __________
Sport(s) _____________________
_____________________
_____________________
Home Address_______________________________ _
City_________________________________
Phone #______________________
State________ Zip____________
Local Phone # (i.e.: dorm, apartment, house, cell) _____________________________________
PARENT INFORMATION:
Father/Guardian ____________________
Address ____________________________
____________________________
Home Phone #_______________________
Work Phone #_______________________
Cell Phone #_________________________
Mother/Guardian ___________________
Address ____________________________
____________________________
Home Phone #_______________________
Work Phone #________________________
Cell Phone #_________________________
Parent's Signature_______________________________________________________________
Student's Signature______________________________________________________________
CUA Pre-participation Physical Exam Packet
Page 3 of 15
Participation will NOT be allowed until this packet is completed
THE CATHOLIC UNIVERSITY OF AMERICA CLUB SPORT’S PROGRAMS
ASSUMPTION OF RISK, WAIVER AND RELEASE FROM LIABILITY
In consideration of the use of the property, facilities and/or services of The Catholic
University of America and the CUA Club Sport’s Program, the undersigned agrees as
follows:
1. Risk Factors- The undersigned understands and acknowledges that the use of
equipment and facilities provided by CUA and participation in Club Sports,
including participation at locations other than CUA, involves risks including but
not limited to the following: risk of property damage, bodily injury, including, but
not limited to permanent disability, paralysis, and possibly death. These risks may
result from the use of the equipment or facilities, from the activity itself, from the
acts of others, or from the unavailability of emergency medical care and may be
unknown or unseen.
2. Assumption of Risk- The undersigned voluntarily assumes all risks that may
arise out of or result from the use of the equipment or facilities, and/or
participation in Club Sports at the Dufour Athletic Center and elsewhere,
including those risks described in Section 1 above. The exception to this
assumption of risk by the undersigned is any injuries caused by the negligence or
willful misconduct of any officers, employees, agents or volunteers of CUA.
3. Acknowledgement of Policies and Procedures- The undersigned acknowledges
reading and knowing all policies and procedures relating to the activities,
facilities, and/or equipment and understands that the safe and proper use of
facilities, equipment or participation in the activity is dependent upon carefully
following such policies and procedures. The undersigned agrees to comply with
and abide by all rules and regulations of the Dufour Athletic Center and of CUA.
The Club Sports Coordinator reserves the right to revoke or terminate the
undersigned’s privileges for any violations of the rules and regulations of CUA or
for any violations of the policies and procedures relating to the activities,
facilities, and/or equipment of the Dufour Athletic Center.
4. Indemnify and Defend- The undersigned hereby releases, waives, indemnifies
and holds CUA and all of its officers, trustees, directors, employees, and agents
and any other person sponsoring or organizing Club Sports at CUA harmless from
any and all claims, causes of action, suits, liability, losses, or damages for any
property damage, property loss or theft, personal injury, death or other loss arising
from or relating to the undersigned’s use of the property, facilities, and/or services
of CUA.
5. Prerequisite Skills- The undersigned acknowledges that he or she has the
requisite skills, qualifications, physical ability and training necessary to properly
and safely use the equipment, facilities, and to participate in the Club Sports and
certifies that to the best of his/her knowledge he/she has no physical condition
that would interfere with his/her ability to participate in Club Sports. The
undersigned agrees that if he or she has any questions as to what skills,
qualifications, or training is necessary to properly use the equipment, facility, or
participate in the Club Sport itself, then he or she shall direct such questions to the
appropriate CUA Staff Member.
6. Waiver- The undersigned waives the protection afforded by any statute or law in
any jurisdiction whose purpose, substance and/or effect is to provide that a
general release shall not extend to claims, material or otherwise which the person
CUA Pre-participation Physical Exam Packet
Page 4 of 15
giving the release does not know or suspect to exist at the time of executing the
release. This means, in part, that the undersigned is releasing unknown future
claims.
7. Pay- The undersigned agrees to pay for any and all damages to any property or to
Indemnified Parties caused by the undersigned negligently, willfully or otherwise.
8. Representatives- The undersigned enters into this agreement for him/herself,
his/her heirs, assigns and legal representatives.
9. Consent for Emergency Treatment- The undersigned, as a participant in the
subject activity, hereby consents to medical treatment in a medical emergency
where the undersigned is unable to consent to such treatment.
10. Insurance- The undersigned understands that CUA does not carry participant
insurance and that the undersigned will be solely responsible for any medical,
health or personal injury costs relating to undersigned’s use of the property,
facilities and/or services of CUA. The undersigned is encouraged to have a
medical physical examination and purchase health insurance prior to any and all
participation.
11. Jurisdiction- This Assumption of Risk, Waiver, and Release from Liability
Agreement shall be governed in all respects by the laws of the District of
Columbia.
12. Severability- If any term, clause, or provision of this Assumption of Risk,
Waiver, and Release from Liability Agreement is held to be illegal, invalid or
unenforceable, or the application thereof to any person or circumstance shall to
any extent be illegal, invalid or unenforceable under present or future laws
effective during the term hereof or of any provisions hereof which survive
termination, then and in any such event, it is the express intention of the parties
that the remainder of this Agreement, or the application of such term, clause or
provision other than to those as to which it is held illegal, invalid or
unenforceable, shall not be affected thereby, and each term, clause or provision of
this Assumption of Risk, Waiver, and Release from Liability Agreement and the
application thereof shall be legal, valid and enforceable to the fullest extent
permitted by law.
13. Acknowledgment- The undersigned has read and fully understands this
agreement and realizes it relates to surrendering and releasing valuable legal
rights and does so freely and voluntarily.
Athlete’s Name: ____________________________________
Athlete’s Signature: ________________________________________Date_______
I am the parent or legal guardian of the above named minor. I have read and understand the agreement and
realize it relates to surrendering valuable legal rights of the minor and myself. I agree to be bound by all the
terms of the agreement. I also give my consent to the participation in the activity of the minor.
Signature of Parent/Legal Guardian Consent and Release on Behalf of the Minor.
Parent/Guardian’s Name: ____________________________________
Patent/Guardian’s Signature: __________________________________Date_______
CUA Pre-participation Physical Exam Packet
Page 5 of 15
Participation will NOT be allowed until this packet is completed
STUDENT ATHLETE AGREEMENT CONCERNING HAZING AND
DANGEROUS INITIATION ACTIVITIES
The Athletics Department maintains a policy prohibiting hazing and dangerous initiation activities. The
Athletics Department interprets hazing and/or dangerous initiation activities as “any act of coercion by a
team representative(s) where another person’s psychological or physical health is endangered.”
Actions and activities which are prohibited by the Athletics Department include, but are not limited to, the
following
1.
2.
Any activity or action that creates a risk to the health or safety of another person.
Any type of initiation or other activity where there is an expectation of individuals joining a
particular team to participate in behavior designed to humiliate, degrade, or abuse them regardless of
the person’s willingness to participate.
Examples of prohibited behavior include:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Forcing, requiring, or pressuring an individual to consume alcohol or any other substance,
Forcing, requiring, or pressuring an individual to shave any part of their body including hair on
their head.
Any requirement or pressure put on an individual to participate in any activity which is illegal,
perverse, publicly indecent, or contrary to his/her genuine moral beliefs, e.g., public profanity,
indecent or lewd conduct, or sexual gestures in public.
Forcing, requiring or pressuring an individual to eat something they would refuse to eat otherwise.
Forcing, requiring or pressuring an individual to tamper with or damage the property of the
University.
Assigning or endorsing pranks such as stealing or harassment of another individual or
organization.
Forcing, encouraging, or pressuring individuals to wear apparel with is conspicuous and designed
to humiliate the individual wearing it.
Required nudity at any time.
Morally degrading or humiliating games or other activity that makes an individual the object of
amusement, ridicule or intimidation.
Subjecting an individual to cruel or harassing language.
Student’s
Name:_______________________________________Team:___________________________
I have been given the opportunity to read this policy and understand the following:
(Initial) _______
(Initial) _______
I understand the policy and regulations of the Athletics Department
pertaining to the prohibition of hazing and/or dangerous initiation activities.
I understand that if I am found in violation of this policy I will be subjected
to discipline by the Athletics Department including suspension from the team.
In addition, I am aware that the team may be subject to group discipline that
can include team probation, cancellation of individual contests, and/or the
cancellation of the entire season.
Signature of Team Member _______________________________ Date ____________________
CUA Pre-participation Physical Exam Packet
Page 6 of 15
Participation will NOT be allowed until this packet is completed.
CONSENT TO MEDICAL TREATMENT FORM AND WAIVER OF LIABILITY
Note: ALL STUDENTS PLANNING TO PARTICIPATE IN THE CUA
CLUB SPORT’S PROGRAMS MUST COMPLETE THIS FORM.
I understand that by signing this form I give permission for my son / daughter,
___________________________, to participate in The Catholic University of
America Club Sport’s Program.
I further understand that in the course of athletic participation serious and
catastrophic injuries can and do occur.
In the event that an injury does occur to my son/daughter in the course of athletics
participation, I give permission to The Catholic University of America, its
certified athletic training staff, and team physician, to proceed with any needed
medical treatment, minor surgery, x-rays, examinations and immunizations.
I understand that in the event of serious illness or catastrophic injury, an attempt
will be made to contact me by the attending physician before performing any
major surgery on my son/daughter. If the attending physician is unable to
communicate with me, I authorize the physician to perform such medical
procedures on my son/daughter as are necessary or advisable.
Moreover, I agree to hold The Catholic University of America, its athletic training
staff, and team physician free and harmless from any claims, demands, or suits for
damages whatsoever which may arise from the participation of my son / daughter
in the Catholic University of America Club Sport’s program: and from any
treatment, medical or otherwise, provided to my son or daughter by The Catholic
University of America, its athletic training staff, or team physicians.
I certify that I have read and understand all the statements contained in this form.
Father’s/Guardian’s Signature _______________________Date_______
Mother’s/Guardian’s Signature _______________________Date_______
Athlete’s Signature ________________________________Date_______
CUA Pre-participation Physical Exam Packet
Page 7 of 15
Participation will NOT be allowed until this packet is completed.
HIPAA Authorization for the Release of Medical Information
The Catholic University of America – Athletic Training Department
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that we guard the privacy of
your protected health information. You have a right to confidential treatment of all information and records
pertaining to your care, as well as full consideration of privacy concerning your treatment and rehabilitation
plan. You also have the right to be advised as to the reason for the presence of any individual during the course
of your medical care. If you sustain an injury while participating in club sports at The Catholic University
of America, it is important to understand that we may need to discuss your injury with your coaches,
parents, and/or other people involved in your care. We may discuss issues relevant to your care only
under the following circumstances:
1.
You have given oral or implied consent through your actions.
2.
You have signed the authorization form below, which permits us to disclose health
information to the parties mentioned.
You have the right to restrict disclosure of your health information to any parties by refusing to sign this form. If
you choose to do so, you must write, “REFUSE TO AUTHORIZE” on the backside of this form in the
appropriate box. Include your SIGNATURE and the DATE for validity purposes.
Please note that even when you have signed the authorization allowing us to share your health information, it
is important to know that we will only release the minimum amount of information necessary to protect you.
Name: _____________________________
(Please print)
Sport(s): _________________________________
(Please print)
This authorizes the certified athletic trainers, physicians, sports medicine staff and other medical
personnel representing The Catholic University of America to release information concerning my
medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable
health information to the coaches, assistant coaches, other athletics staff, my parents/guardians, and the
media when deemed appropriate. This information includes injuries or illnesses relative to past, present
or future participation in athletics at The Catholic University of America.
The reason for this disclosure is to advise my coaches and the athletics staff about the diagnosis or
treatment concerning my medical condition so that they may make decisions regarding my athletic
ability to compete while I am a student athlete. This disclosure is also used to advise my parent/guardian
of the diagnosis or treatment concerning my medical condition so that they may assist me in making
healthcare decisions while I am a student athlete. In certain circumstances, this disclosure is also to
advise print, radio, television and other media of the nature and treatment concerning my medical
condition so that they may report on it while I am a student athlete. I understand that the entities that
receive the information are not health care providers or health plans covered by federal privacy
regulations, and that the information described above may be re-disclosed publicly and the information
will no longer be protected by those regulations.
I understand that The Catholic University of America will not receive any compensation for its use of the
information. I understand that I may refuse to sign this authorization and that my refusal to sign will not
affect my ability to obtain treatment. I may inspect or copy any information used under this
authorization. I understand I may revoke this authorization at any time by notifying the Head Athletic
Trainer in writing. This authorization expires six years from the date it is signed.
_________________________________________
Signature of Student-Athlete
_______________________________
Date
_________________________________________
Signature of Parent/Legal Guardian
(If student-athlete is under 18 years of age)
_______________________________
Date
CUA Pre-participation Physical Exam Packet
Page 8 of 15
Participation will NOT be allowed until this packet is completed.
General Medical History (2011-12)
Athlete’s Name: ___________________________
Please explain all YES answers in the space provided under each question or on back page.
Regarding Injury or illness occurring in the past four (4) years:
Have you ever had an illness or disorder that:
Yes
Yes
No
No
required you to stay in the hospital Date: __/__/__ Condition: _____________
required an operation? Date: __/__/__ Condition: _____________
Have you been diagnosed with any of the following illnesses, disorders, or conditions:
Please check appropriate response and give date of diagnosis.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Thyroid Disease
Date: __/__/__
Asthma
Date: __/__/__
Pneumonia
Date: __/__/__
Tuberculosis
Date: __/__/__
Sickle Cell Anemia
Date: __/__/__
Sickle Cell Trait
Date: __/__/__
Diabetes
Date: __/__/__
Seizure disorder
Date: __/__/__
Most recent seizure date: __/__/__
Mononucleosis
Date: __/__/__
Hepatitis
Date: __/__/__
ADHD
Date: __/__/__
Heart Murmur
Date: __/__/__
Arrhythmia
Date: __/__/__
Hypertension
Date: __/__/__
Other heart condition
Date: __/__/__
Condition: ________________
Methicillin Resistant Staphylococcus Aureus (MRSA)
Date: __/__/__
Do you take any medications on a regular, continuing, or seasonal basis?
Name: ________________________________
Dosage: _______________________________
Yes
No
Yes
Yes
No
No
Yes
No
Do you have allergies to any medications?
Name: ________________________________
Are you allergic to bee stings?
Do you have allergies to insects, pollen, dust, grass, foods, adhesive tape, latex, or benzoin?
If yes, list: _____________________________________
Do you have your own epipen (epinephrine auto-injector)?
Yes
No
Do you have frequent ear or eye infections?
Yes
No
Do you have any skin conditions? (ringworm, herpes, eczema, warts, fungus, or athlete’s foot)
If yes, list: ____________________________________________
Yes
Yes
No
No
wear glasses or contacts?
wear dental bridges, plates, or braces?
Yes
Yes
Yes
No
No
No
Have you ever:
been dizzy or passed out during or after exercise?
wheezed with exercise?
chest pain during exercise?
Yes
Yes
Yes
No
No
No
Have you ever suffered from:
Heat Cramps?
Heat Exhaustion?
Heat Stroke
Do you:
CUA Pre-participation Physical Exam Packet
Page 9 of 15
Participation will NOT be allowed until this packet is completed
2011-12 General Medical History, Continued
Yes
No
Do you have absence of paired organ?
Eye
Ear
Kidney
Lung
For males:
Yes
No
Are you missing a testicle?
For females:
Yes
Yes
Yes
No
No
No
Are you missing an ovary?
Are your menstrual periods irregular?
Are your menstrual periods absent (amenorrhea)?
Yes
No
Have you ever been advised to permanently not participate in sports?
Medical reason___________________________
Yes
No
Do you take vitamins, amino acids, creatine, and/or any other dietary
supplements?
If so, which ______________________________
FAMILY HISTORY: (Only check if YES)
Mother
Father
Maternal
Grandparents
Paternal
Grandparents
Sibling
Sudden Death Before Age 5
Heart Disease
Hypertension
Cancer
Epilepsy (Seizures)
Bleeding Disorder
Diabetes
Other
Please explain any “Yes” answers to any and all of the general medical history questions.
______________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Athlete’s Signature______________________________________
Date________________
CUA Pre-participation Physical Exam Packet
Page 10 of 15
Participation will NOT be allowed until this packet is completed.
Orthopedic History (2011-12)
Athlete’s Name: _____________________
Please explain all YES answers in the space provided under each question or on back page.
Regarding injuries occurring in the past four (4) years:
Head
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Concussion
Number of concussions: 1 2 3 ____
Degree / Severity:
mild moderate severe
Date(s) of injury: __/__/__
Required Hospitalization
Dates of Hospitalization: __/__/__ to __/__/__
CT scan results: _____________________________
Migraine Headaches
Neck / Cervical Spine
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Neck Stiffness / Pain
Pinched / Stretched nerve, Nerve root injury
Burners, Stingers
Sprain / Strain, Whiplash
Cervical Spine Stenosis
Disc Injury (herniated, prolapsed, ruptured, removal)
Fracture
Axial Load Injury (jammed neck)
Surgery (fusion)
Transient Quadriplegia (temporary paralysis)
Spine / Low Back / Hip
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Stiffness / Pain
Limited motion of the Spine
Spondylolsis / Spondylolisthesis
Stress fracture
Lumbar Disc Injury (herniated, prolapsed, removal)
Narrowing of disc space as determined by x-ray
Scoliosis, Lordosis, Kyphosis
Low Back Surgery
Date __/__/__ Condition: ______________
Limited hamstring flexibility
Sciatica
Sacroiliac joint injury
Avulsion Fracture
Dislocated Hip
No
No
No
No
No
No
No
Separation (Acromion Clavicular Sprain) L / R
Subluxation / Dislocation L / R
Impingement/ Thoracic Outlet L / R
Rotator Cuff Tendonitis / Tear L / R
Bicipital Tendonitis / Bursitis L / R
Surgery (Labrum, Rotator Cuff, Decompression, Capsular Shift) L / R
Sprain/Strain L / R Mild Moderate Severe
Shoulder
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CUA Pre-participation Physical Exam Packet
Date __/__/__
Page 11 of 15
Participation will NOT be allowed until this packet is completed
2011-12 Orthopedic History, Continued
Elbow / Wrist / Hand
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Strain / Sprain / Hyperextension (Elbow, Wrist, Hand, Finger) L / R
Fracture ( Elbow, Wrist, Hand, Finger ) L / R
Dislocation ( Elbow, Wrist, Finger ) L / R
Medial epicondylitis ( Little League Elbow ) L / R
Lateral epicondylitis ( Tennis Elbow ) L / R
Navicular (Scaphoid) fracture of the wrist L / R
Carpal Tunnel Syndrome of the wrist L / R
Torn ulnar collateral ligament of thumb (Gamekeepers Thumb) L / R
Surgery ( Elbow, Wrist, Hand, Finger ) L / R Date __/__/__
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Ligament Sprain:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Knee
ACL
L / R
Date __/__/__
MCL L / R
Date __/__/__
PCL
L / R
Date __/__/__
LCL
L / R
Date __/__/__
Ligament Surgery: L / R Ligament _______ Date __/__/__
Meniscus Tear: Medial
L / R
Date __/__/__
Lateral
L / R Date __/__/__
Meniscus Surgery: L / R Date __/__/__
Menisectomy
Repair
Hyperextension
L / R
Patellar Tendonitis / Osgood Schlatters L / R
Chondromalacia
L/ R
Bursitis / Tendonitis / Bakers Cysts L / R
Patellar Dislocation / Subluxation
L/R
Plica / Chronic Swelling
L/R
Other Surgery
Date __/__/__ Condition: _____________
Lower Leg, Ankle and Foot
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Sprain L / R Mild Moderate Severe
Achilles Tendonitis / Bursitis L / R
Dislocation / Fracture L / R
Stress Fracture (Tibia, Metatarsal) L / R
Anterior Compartment Syndrome
Pump Bump, Bunion, Neuroma L / R
Fallen Arches / Flat Foot / Wear Orthotics L / R
Please explain any “Yes” answers to any and all of the orthopedic history questions.
____________________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Athlete’s Signature______________________________________
Date________________
CUA Pre-participation Physical Exam Packet
Page 12 of 15
Participation will NOT be allowed until this packet is completed.
PRIMARY INSURANCE INFORMATION
Please affix a LEGIBLE xerox copy, FRONT and BACK, of medical insurance card(s).
Athlete’s Name: ____________________________Primary Care Physician:______________
PCP Phone #: _______________________
Primary Medical Insurance Card
Policy Holder’s Name:_________________________________________
Policy Holder’s Date of Birth:___________________________________
FRONT
AFFIX CARD HERE
BACK
AFFIX CARD HERE
Secondary Medical Insurance Card (IF APPLICABLE)
Policy Holder Name:_______________________________
Policy Holder Date of Birth:____________________________
FRONT
AFFIX CARD HERE
CUA Pre-participation Physical Exam Packet
BACK
AFFIX CARD HERE
Page 13 of 15
Participation will NOT be allowed until this packet is completed.
The Catholic University of America
Pre-Participation Physical Exam Form
2011-12
Date received (office use only):
Athlete’s Last Name: _________________
Athlete’s First Name: _________________
Sex: M / F
Height: ________
Sport(s): __________________________
M.I.: ______
Weight:
Class:
Fr
Soph
Jr
DOB: ___/___/___
_______
Sr
5th Other __________
SSN: _____ - ___ - _____
Below for Physician use only:
GENERAL
___ Physician’s Review of Student Athlete’s Medical History
(Catholic University’s General / Orthopedic History Form)
Vision:
Left
Right
SKIN
Uncorrected
____ / ____
____ / ____
Corrected
____ / ____
____ / ____
___ WNL
Glasses:  Yes  No
Contacts:  Yes  No
HEAD
Dominance:
Hand:  Left  Right
Foot :  Left  Right
___ WNL
Scars
____________________
Birthmarks ___________________
Sweat
____________________
Texture ____________________
Tatoos
____________________
Eyes: Lids____ Sclera ____ Conjuctiva ____ Pupil ____ Fundi ___
Ears: Pinna ___ R __ L__ Canal ____ R __ L __ Drum __ R __ L __
Nose: Septum ____ Mucosa R ___ L ___
Mouth: Lips ___ Tongue ___ Pharynx ___ Tonsils ___ Teeth ___
NECK ___ WNL
CHEST / LUNGS
Thyroid
Trachea
Veins
Spine
Disc
Chest
______ Bruit
______
Sounds ______ Diaphragm ______
Fremitus ______ Symmetry ______
___
___
___
___
___
Nodes ___ R __ L __
Bruit ___ R __ L __
Carotid ___ R __ L __
Motion ___
Brachial Plexus R ___ L ____
Abnormal findings:
Abnormal findings: _______________________
_______________________
_______________________
___ WNL
_______________________
_______________________
_______________________
CARDIOVASCULAR EXAMINATION
Heart Rate
Blood Pressure
Respiration's / min
Rhythm
Murmurs
At Rest
___________________
_______________
___________________
___________________
___________________
Is there any evidence of Marfan’s Syndrome? (i.e. high arched palate, displaced lens, pectus excavatum, arm span one greater that height, heart murmurs)
Yes _____ No _____
Based on the history and the physical examination, the following conditions should receive further cardiac evaluation: family history of premature heart disease, student
history of syncope. Palpitations, chest pain with exercise, shortness of breath or easily fatigued, BP two (2) or more SD above normal, height 97th percentile or above, all
diastolic murmurs, systolic murmurs of grade 2 or above, apical murmurs which increases with valsalva, ejection sounds or gallops, rhythm disturbances, heart rate not
returning to 20%or resting rate by five (5) minutes, decreases in heart rate during exercise, heart rate does not rise above 60 with exercise, or known pre-existing heart
disease.
CUA Pre-participation Physical Exam Packet
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ABDOMEN
___ WNL
Contour
Tenderness
Organs
Masses
Hernia (Male)
Inguinal nodes
Abnormal Findings:
____
____
____
____
R ____ L ____
R ____ L ____
________________________
________________________
BACK
___ WNL
Scoliosis ____
Trunk Flexion
____
Kyphosis ____
Trunk Extension
____
Lordosis ____
Lateral Flexion
R ___ L ___
Spondylolisthesis ____
Trunk Rotation
R ___ L ___
L5 - S1 Disc ____
Hamstring Tightness R ____ L ____
Patellar Reflex ____
Achilles Reflex
_____
Abnormal Findings: ________________________________
________________________________
ORTHOPEDIC EVALUATION OF EXTREMITIES / JOINTS
Shoulder:
ROM
L __ R __ Abnormal findings _______________
___ WNL
Strength L __ R __ Abnormal findings ______________
___ WNL
Laxity
L __ R __ Abnormal findings ______________
___ WNL
ROM
L __ R __ Abnormal findings: _______________
___ WNL
Strength L __ R __ Abnormal findings: _______________
___ WNL
Laxity
L __ R __ Abnormal findings: _______________
___ WNL
ROM
L __ R __ Abnormal findings: _______________
___ WNL
Strength L __ R __ Abnormal findings: _______________
___ WNL
Laxity
___ WNL
Knee:
Ankle:
L __ R __ Abnormal findings: _______________
Summary of findings:
Medical Clearance:
1. ________________________
______ Cleared without restriction
2. ________________________
______ Failed Pre-Participation Athletic Examination, no participation,
Corrective treatment required: __________________________
3. ________________________
______ Cleared for _________________________ (sport) after
completing evaluation / rehabilitation of:
______________________________________
4. ________________________
Physician’s Signature: ______________________________________
Date: ____________
Physician’s Address:
______________________________________
______________________________________
______________________________________
Phone number:
CUA Pre-participation Physical Exam Packet
(
) ___________________________
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