The physical exam form package includes six pages, and student-athletes are asked to print out all of the pages to be reviewed and filled out:
(Page 1-2) Physical Medical History
(Page 3) Physical Evaluation Form
(Page 4-5) Contact Information and Insurance Status Form
(Page 6) Acknowledgement of Risk Statement
Parent's Please Read - Athletic Insurance Coverage
All forms should be printed legibly in black or blue ink only
After printing the forms, please complete pages 1 and 2 Confidential Report of Medical History before seeing your Doctor. Your Doctor should review these two forms prior to examining you. Only your doctor should complete and sign page 3, Report of Health Evaluation.
The Contact Information Sheet asks for temporary school contact information and your parents' (permanent) contact information; as well as parents' employment information. You may not have all school contact information until you arrive on campus.
The Student-Athlete Insurance Status Form requests information regarding your insurance coverage. All pertinent information can be found on your insurance card. Please transfer the appropriate information onto the form, and provide a copy of both sides of all related insurance cards (medical, dental and prescription). You may also bring your cards with you to the Training Room when you arrive, and the staff will make the necessary copies.
Read the Acknowledgement of Risk Statement and Authorization/Consent for Disclosure of PHI with your parents. Make sure to print your name, initial or sign as indicated.
Note: Anywhere there is a grey shaded "signature" box, please make sure that the appropriate person signs it.
Turn in all of the completed and appropriately signed forms to the Athletic Training Staff when you arrive on campus. All 6 forms must be checked and approved by the Training Staff prior to any athletic practice or participation. Do not attempt to mail in the forms, unless you keep a copy for your files.
Also included is a two page document entitled Important Information on Athletic Insurance Coverage. Print these forms and have your parents review them closely. If you have any questions regarding insurance coverage, do not hesitate to contact the Athletic Training Room at (956)-381-2233.
