Pre-Participation Physical Examination Packet for
Returning Varsity Athletes checklist:

Fill out pages 3-9 in 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 8-9 to be filled out by Physician

Athletes that have been diagnosed with Attention Deficit Hyperactivity Disorder
(ADHD), please read page 2 for detailed instructions for supporting documentation for
prescription medication. This is an NCAA requirement!

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 Friday, July 31, 2009. 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.
**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 9
Attention Deficit Hyperactivity Disorder (ADHD) Guideline Attachment
Criteria for letter from prescribing Physician to provide documentation to the Sports Medicine staff
regarding assessment of student-athletes taking prescribed stimulants for Attention Deficit
Hyperactivity Disorder (ADHD), in support of an NCAA Medical Exception request for the use of a
banned substance.
The following must be included in supporting documentation:




Student-athlete name
Student-athlete date of birth
Date of clinical evaluation
Clinical evaluation components including:
o Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) – attach
supporting documentation
o ADHD Rating Scale (s) (e.g., Connors, ASRS, CAARS) scores and report summary –
attach supporting documentation
o Blood pressure and pulse readings and comments
o Note that alternative non-banned medications have been considered, and comments
o Diagnosis
o Medication (s) and dosage
o Follow-up orders
Additional ADHD evaluation components if available:






Report ADHD symptoms by other significant individual (s)
Psychological testing results
Physical exam date and results
Laboratory/ testing results
Summary of previous ADHD diagnosis
Other comments
Documentation from prescribing physician must also include the following:




Physician name (printed)
Office address and contact information
Specialty
Physician signature and date
NOTE: This requirement is strictly a NCAA requirement, and this information must be
on file in the athletic training room prior to any competition. This information is
necessary to appropriately apply the NCAA Medical Exceptions policy on banned
substances. This is also necessary so that student-athletes are adequately monitored while
using a stimulant medication that can negatively impact health and safety, and so that
stimulants are not being used strictly for athletic performance enhancement.
CUA Pre-Participation Physical Exam Packet
Page 2 of 9
Date received of completed 2009-10
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 #_________________________
CONSENT TO MEDICAL TREATMENT FORM AND WAIVER OF LIABILITY
I understand that by signing this form I give permission for my son / daughter, ___________________________, to participate in The
Catholic University of America Varsity Intercollegiate Athletics Program.
I further understand that in the course of athletics 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 Varsity Intercollegiate Athletics 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.
In addition, I hereby authorize the Catholic University of America and the athletic department’s secondary insurance agent to inspect
or secure copies of case history records, laboratory reports, diagnosis, x-rays, and any other data covering this and/or previous
confinements and/or disabilities. A photocopy of this form shall be deemed as effective and valid as the original.
We authorize that the university or its insurance agent pay the medical vendors direct for any bills incurred from the accidents that are
covered under the coverage purchased by the university.
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_______
CUA Pre-Participation Physical Exam Packet
Page 3 of 9
Athlete’s Signature ________________________________________Date_______
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 4 of 9
Participation will NOT be allowed until this packet is completed.
HIPAA Authorization for the Release of Medical Information
The Catholic University of America – Sports Medicine 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 intercollegiate athletics 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 be refusing to sign this form. If
you choose to do so, you must write, “REFUSE TO AUTHORIZE” on the next 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)
CUA Pre-Participation Physical Exam Packet
Date
Page 5 of 9
REFUSE TO AUTHORIZE
If you REFUSE to disclose your information to a particular entity please place a check mark by the specific
person or groups of people you would like the medical staff NOT to release medical information to. Then place
your signature and date in the area provided. Also you must write “REFUSE
space provided at the bottom.
_____ Physicians
_____ Medical Professionals
_____ Coaching Staff
_____ Parents/Guardians
_____ Media
_____ Professional Team Personnel
TO AUTHORIZE” in the
_______________________________
__________
Signature
Date
_______________________________
__________
Signature
Date
_______________________________
__________
Signature
Date
_______________________________
__________
Signature
Date
_______________________________
__________
Signature
Date
_______________________________
__________
Signature
Date
If you REFUSE to authorize disclosure to any of these entities, please write, “REFUSE TO AUTHORIZE” here.
CUA Pre-Participation Physical Exam Packet
Page 6 of 9
Participation will NOT be allowed until this packet is completed.
General Medical / Orthopedic History for Returning Student- Athletes (2009-10)
Athlete’s Name: ___________________________
Please explain all YES answers in the space provided under each question or on the next page.
Regarding Injury or illness occurring in the past year:
Have you had an illness or disorder that:
Yes
Yes
No
No
required you to stay in the hospital?
required a visit to the emergency room?
Yes
Yes
No
No
required an operation?
required a visit to your family physician?
Yes
No
Do you take any medications on a regular, continuing, or seasonal basis?
Name(s): _______________________________________________________________
Dosage(s): ______________________________________________________________
Yes
No
Do you have your own epipen (epinephrine auto-injector)?
Yes
No
Do you have any skin conditions? (ringworm, herpes, eczema, warts, fungus, or athlete’s foot)
If yes, list: _______________________________________________________________
Yes
No
Do you:
wear glasses or contacts?
Yes
Yes
Yes
Yes
No
No
No
No
In the past year, have you suffered an injury to your:
head/ neck?
spine and low back?
lower extremity (hip, knee, lower leg, ankle, foot)?
upper extremity (shoulder, elbow, wrist, hand)?
Yes
No wear dental bridges, plates, or braces?
Please list all allergies to medications, bee stings, grass, pollen, dust, foods, adhesive tape, latex, or benzoin.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please explain any “Yes” answers to any and all of the general medical/ 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 7 of 9
Participation will NOT be allowed until this packet is completed.
The Catholic University of America
Pre-Participation Physical Exam Form
2009-10
Date received (office use only):
Athlete’s Last Name: _________________
Athlete’s First Name: _________________
Sex: M / F
Height: ________
Sport(s): __________________________
M.I.: ______
Class:
Fr
Soph
Jr
DOB: ___/___/___
Weight: _______
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
____ / ____
____ / ____
___ WNL
Corrected
____ / ____
____ / ____
HEAD
Glasses:  Yes  No
Contacts:  Yes  No
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
Page 8 of 9
ABDOMEN
___ WNL
BACK
Contour
Tenderness
Organs
Masses
Hernia (Male)
Inguinal nodes
Abnormal Findings:
____
____
____
____
R ____ L ____
R ____ L ____
________________________
________________________
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: ________________________________
________________________________
___ WNL
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:
Summary of findings:
1.
________________________
2.
________________________
3.
________________________
4.
________________________
L __ R __ Abnormal findings: _______________
Medical Clearance:
______ Cleared without restriction
______ Failed Pre-Participation Athletic Examination, no participation,
Corrective treatment required: _______________________________
______ Cleared for _________________________ (sport) after
completing evaluation / rehabilitation of:
______________________________________
Physician’s Signature: ______________________________________
Date: ____________
Physician’s Address:
______________________________________
______________________________________
______________________________________
Phone number:
CUA Pre-Participation Physical Exam Packet
(
) ___________________________
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