Cuesta College Athletic Training
PO Box 8106 (HWY 1), San Luis Obispo, CA 93403-8106
(805) 546-3225 ph. • (805) 546-3158 Fax
Dear Cuesta Student Athletes and Parents,
Cuesta Athletics abides by the medical policies set forth by the California Community College
Athletic Association Constitution and Bylaws (CCCAA). Cuesta participates in the Student
and Intercollegiate Athletic Accident Insurance program. This program provides secondary
(or excess) coverage for injuries sustained while participating in practice or play of
intercollegiate athletics. This means that the student-athlete’s primary insurance will be
billed first in all cases and the remaining amount, if any, must be submitted to the
department’s secondary insurance for payment consideration. The department’s policy has a 52
week period of benefits from the date of the original injury.
In an effort to manage insurance and medical expenses, the Department of Athletics requires
that all student-athletes provide evidence of primary medical insurance before commencing
intercollegiate practice or play. Failure to provide evidence of insurance coverage may prevent
a student-athlete from participating in intercollegiate athletics’ activities. Please ensure that the
information on the attached questionnaire is completed accurately.
In the event that the individual is a member of a health maintenance organization, such as
Kaiser or Blue Shield HMO, we are required to send the athlete to their primary care physician
for treatment. We encourage student athletes to change their primary care physician to the San
Luis Obispo area in order to expedite the process should they become injured. This is also
beneficial for those athletes who have illnesses that the Student Health Center is not equipped
to handle. We hope you can understand that with ever-increasing medical costs we must utilize
all possible coverage for proper financial management and at the same time provide good
health care.
Listed below are the procedures each student athlete must follow should they become injured
during sport participation:
1. All injury evaluation and follow-up care must be done through the Athletic
Training Room (ATR).
2. When the athlete is seen inside the ATR the athletic trainer will write out an injury
report form. The athlete will then be given instructions for care of the injury. This
may include going to the Health Center or signing up to see one of the team
physicians during the clinic hours in the ATR.
3. If it has been determined that the student athlete will require treatment off campus, a
Student Insurance claim form must be filled out. This form must be completed by
the athlete and by a Cuesta Athletic Trainer. Any athlete who seeks medical care
off campus for an athletically related injury without first consulting with the ATR
will not be covered by the Cuesta insurance.
4. If the athlete requires an off campus visit to a medical provider it must be
coordinated through the athlete’s primary insurance. This may mean calling for
authorization or visiting the primary care physician.
1
5. If the athlete or the athlete’s parents receive bills or explanation of benefits in the
mail, they must be forwarded to:
Student Insurance
10801 National Blvd., Suite 603
Los Angeles, CA 90064
If you do not have the itemized bills and explanation of benefits you cannot
proceed with payment from the Student Insurance Group.
6. Each injured athlete’s medical status will be reviewed with the respective head
coach on a regular basis to determine ability to participate.
I have enclosed a Medical History Questionnaire along with the Insurance Information sheet.
Please return these to the Athletic Training Room or Athletic Director. Remember that the
training room must have this information prior to any participation with your Cuesta Team.
I greatly appreciate your time and consideration in this matter. If you have any questions,
please call the athletic training room at (805) 546-3225.
Sincerely,
Cuesta Athletic Training Staff
2
CUESTA ATHLETIC TRAINING FACILITY GUIDELINES
1. You MUST take a shower before any type of treatment, evaluation, or use of the
whirlpools.
2. Sign in if you are receiving treatment (including ice, meds and equipment).
3. DO NOT remove any equipment or supplies from the Athletic Training Facility without
authorization and without signing out.
4. This is a co-ed Athletic Training Facility, proper attire is required.
5. Whirlpool
a. Attire for all: clean swim suit. NO SPANDEX.
b. No open wounds or blisters in whirlpool.
c. Bring your own towel.
d. Whirlpool temp should not be lower than 55°F.
e. Dry off before leaving whirlpool area.
6. Absolutely no eating or tobacco use in the Athletic Training Facility unless given
permission.
7. Keep cell phone use to a minimum and NEVER when talking to an athletic trainer or
physician. Use head phones for your music.
8. Athletic injuries must be evaluated by an Athletic Trainer prior to seeing a physician in
the Athletic Training Facility.
9. You must notify the Athletic Training Staff if you plan to seek medical attention for an
athletic injury outside of the Athletic Training Facility.
10. Please remember this is a medical facility and we ask that you treat it as such.
11. Refrain from any improper language, horseplay, or behavior that is unbecoming of a
Cuesta Student-Athlete.
Thank You,
Athletic Training Staff
3
4
Cuesta Intercollegiate Athletic
Insurance Questionnaire
For Office Use Only
Ent
Comp
Accident/Injury benefits for athletes are provided on an “excess” basis. This means ATHLETE’S OWN GROUP INSURANCE OR
THAT OF THE ATHLETE’S SPOUSE AND/OR PARENT MUST BE BILLED FIRST. Benefits are available from our program only
when the Athlete’s coverage is exhausted or does not apply. The following information is essential to assure that expenses are
adequately and completely covered by the proper insurance. Inadequate or incomplete answers will delay payment of medical
bills and may jeopardize the athlete’s credit rating. No medical expenses will be paid out of institutional funds without a signed,
accurate questionnaire on file. It is the athlete’s sole responsibility to keep the information contained in this document current.
ATHLETES INFORMATION
First Name
MI
***WRITE CLEARLY; IF WE CAN’T READ IT, WE WON’T ACCEPT IT***
Last Name
SS#
Cit y
Local Address
Student ID #:
State
Year in School: FR
DO YOU HAVE INSURANCE: YES
NO
SO
Zip
D.O.B.
Sport
Phone
Cell Phone
✔
✔
Please list the Medical Insurance Policies You Have Below
Primary Insurance
Subscriber’s Name
Secondary Insurance
Subscriber’s SS#
Subscriber’s Name
Subscriber’s SS#
Employer
Employer
Insurance
✔
Insurance
✔
Insurance Billing Address
Insurance Group #
Claims Phone #
Insurance Billing Address
ID/Policy #
Authorization Phone #
Dental Insurance Coverage
Dental Insurance
Dental Policy #
Dental Subscriber
Dental Phone #
Insurance Group #
Claims Phone#
ID/Policy #
Authorization Phone #
Vision Insurance Coverage
Vision Insurance
Vision Policy #
Vision Subscriber
Vision Phone #
I/We hereby certify that the foregoing answers are true, complete and correct to the best of my/our knowledge. I/we also
hereby authorize any Insurance Company, Organization, Employer, Hospital, Physician, Surgeon, Pharmacy, or other health
care provider to release any information with respect to injury, treatment, or insurance. A photo static copy of this
authorization shall be considered as effective and valid as the original.
Signature of Parent or Guardian
Signature of Athlete
Date
Date
5
New Student-Athlete Medical History Questionnaire
Sport:
Date:
Sex: M
Age:
F
Name:
Last
Social Security #:
First
Middle
Email Address:
Permanent Address
Street:
City:
Home Phone: ( )
State:
Cell Phone (
Zip:
)
Email:
Father/Guardian:
Street:
City:
Home Phone: ( )
State:
Work: (
)
Cell: (
Zip:
)
Cell: (
Zip:
)
Email:
Mother/Guardian:
Street:
City:
Home Phone: ( )
Work: (
)
Emergency Contact
Name:
Home Phone: ( )
Work: (
)
State:
Relationship:
Cell: ( )
GENERAL MEDICAL HEALTH HISTORY
HAS ANY BLOOD RELATIVE
EVER HAD …
SUDDEN DEATH
(BEFORE AGE 55)
BLOOD DISEASES
(SICKLE CELL, LEUKEMIA)
DIABETES
EPILEPSY
GOUT
HEART DISEASE
HEMOPHILIA
HIGH BLOOD PRESSURE
NEUROLGICAL DISORDERS
STROKE
TUBERCULOSIS
ASTHMA
GLAUCOMA
COMMENTS:
YES
NO
WHO
✔
6
GENERAL MEDICAL HEALTH HISTORY
Do you have or have you EVER had any of the following medical conditions?
YES NO
HIGH BLOOD PRESSURE
RHEUMATIC HEART
DISEASE
RHEUMATIC FEVER
PERICARDITIS
ANY HEART DISEASE?
TUMOR, GROWTH, CYST,
CANCER
ANY RUPTURED ORGANS?
HEPATITIS
JAUNDICE
SICKLE CELL ANEMIA /
CARRIER
PLEURISY
PNEUMONIA
POLIO
BRONCHITIS
TUBERCULOSIS
FREQUENT RESPIRATORY
INFECTIONS
MALARIA
MUMPS
MONONUCLEOSIS
RUBELLA
RED MEASLES / RUBEOLA
CHICKEN POX
ARTHRITIS
EAR INFECTION
HEARING DEFECT / LOSS
MUSCULAR DISEASE
STOMACH ULCER (PEPTIC)
BIRTH DEFECTS
APPENDICITIS
GOUT
CONSTIPATION
HEMORRHOIDS
HERNIA
COMMENTS:
✔
✔
YES NO
ASTHMA
EXERCISE INDUCED
ASTHMA
SINUS INFECTION
NASAL POLYPS
NOSE FRACTURE
SEIZURE DISORDER/
EPILEPSY
MENINGITIS
MIGRAINE HEADACHES
AMNESIA
GOITER, THYROID DISEASE
SKIN DISEASE
DIABETES
ANEMIA
ABNORMAL BRUISING
ABNORMAL BLEEDING
GASTROINTESTINAL
BLEEDING
BLOOD DISEASE
BLOOD CLOTS
KIDNEY DISEASE
KIDNEY INJURY
KIDNEY STONES
URINARY INFECTIONS
BLOOD IN URINE
JOINT INFLAMMATION
HERPES (ORAL)
HERPES (GENITAL)
SEXUALLY TRANS.
DISEASES
EATING DISORDER
CAR OR AIR SICKNESS
NERVOUS BREAKDOWN
MENTAL DISORDER
DRUG DEPENDENCY
7
Do you CURRENTLY HAVE any of the following SYMPTOMS or PROBLEMS?
YES NO
FREQUENT HEADACHES
VISUAL CHANGES
EAR PAIN /HEARING
CHANGES
SORE THROAT
SINUS CONGESTION
BREATHING DIFFICULTY
RECURRING COUGHING
CHEST PAIN
COMMENTS:
YES NO
ABDOMINAL PAIN
MUSCLE CRAMPS
NAUSEA, VOMITING,
DIARRHEA
PENILE DISCHARGE
VAGINAL DISCHARGE
RECTAL BLEEDING
UNUSUAL FATIGUE
BLOOD IN URINE
INTERNAL
To your knowledge, were you born with a complete and functioning set of paired organs (eyes,
ears, kidneys, ovaries/testicles, lungs)?
YES
NO
✔
If not, which organs are involved?
Have you ever had surgery to repair or remove any organ (hernia, testicles, appendix, spleen,
kidney)?
YES
NO
✔
If yes, which organ?
Repaired
Physician:
_ Removed
Date
Address:
CARDIAC
YES NO
Have you ever felt dizzy, light headed or passed out during or after exercise?
Have you ever had chest pain while exercising?
Have you ever had irregular heartbeats or heart palpitations?
Have you ever been told you have a heart murmur?
Have you ever been seen by a heart specialist (cardiologist)?
If Yes?
Who:
Date:
Have you ever had an echocardiogram?
Have you ever had a stress (heart) test?
COMMENTS:
8
VISION
YES NO
Have you ever been to an eye doctor?
Do you wear glasses now?
If Yes, Reading only?
Distance only?
All the time?
Do you wear Contact Lenses?
If Yes, Soft Lenses?
Hard Lenses?
Do you have a second pair of contacts?
Do you wear contact lenses / glasses to participate?
Have you ever had an eye injury?
Date:
Explain:
Is your color vision normal?
Have you ever worn a false eye?
Date of last eye exam
PHYSICIANS NAME:
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
PRESCRIPTION
RIGHT:
LEFT:
DENTAL
DATE OF YOUR LAST DENTAL VISIT?
YES NO
Do you have a bridge or false teeth?
Have you ever fractured a tooth?
Have you had a tooth knocked out?
Do you wear a mouth protector?
Do you wear orthodontic appliances?
Have you had your wisdom teeth removed?
If Yes?
Date:
COMMENTS:
HEAT
Have you ever experienced any of the following?
Trouble with dehydration (excessive loss of salt and water)?
Heat exhaustion or heat stroke?
Heat cramps (Due to fluid loss in excessive heat)?
Have you ever been hospitalized for heat illness?
COMMENTS:
YES NO
9
ALLERGIES
ARE YOU ALLERGIC TO . . .
Aspirin
Codeine
Cortisone
Sulfa
Anti-Inflammatory Meds
Penicillin
Antibiotics
Insect Bites / Stings
Tetanus Antitoxin or Serums
Nail Polish or Cosmetics
Any foods
Any other drug:
Pollens, trees, grasses
Other:
COMMENTS:
YES NO
MISCELLANEOUS
Have you ever . . .?
Worn hearing aids
Stuttered or stammered
Coughed up blood
Bled excessively after injury
Been advised to have any operations
Do you have any pins, staples, or wires in any part of your body?
Had any illnesses other than those already noted?
Have you ever missed a game because of illness?
COMMENTS:
YES NO
DRUG, FOOD SUPPLEMEMTS AND MISCELLANEOUS AGENTS
Check the appropriate space according to your use of the following items:
NEVER
Vitamins
Diet Pills
Sleeping Pills
Laxatives
Alcoholic Beverages
Antihistamines
Anti-inflammatory Meds
Caffeine
Tobacco
Other Drugs:
Steroids
Amino Acids
Protein Supplements
RARELY
OCCASIONALLY
FREQUENTLY
✔
List all medications that you are currently taking and why?
10
GENERAL MEDICAL HEALTH HISTORY –CONT—
FOR FEMALE ATHLETES ONLY; MALES PROCEED TO NEXT PAGE
WOMEN’S HEALTH
HISTORY
YES NO
Are your periods regular
Age of onset:
Date of last period:
Interval between periods:
Duration of periods:
Is flow heavy?
Is heavy bleeding ever a problem?
Do you ever have bleeding between periods?
Do you experience any unusual discharge?
Are cramps a frequent problem during your period?
Any past pregnancies / births?
Do you use oral contraceptives?
If yes, what brand name?
Do you do monthly breast self-examinations?
Do you have frequent urinary tract infections?
Have you ever had a blood clot in your veins?
Have you ever been treated for anemia?
Have you ever had a gynecological exam?
Date:
Have you ever had a pap smear?
Date:
Have you ever had an abnormal pap smear?
Have you ever been treated for eating disorders?
Do you wish to see a dietician?
✔
✔
✔
COMMENTS:
11
ORTHOPEDIC HISTORY QUESTIONAIRE
(All Athletes)
PLEASE PLACE A CHECK IN EITHER THE “YES” OR “NO” BOX.
Have you ever injured or consulted a doctor about any injury to . . .
HEAD
YES
NO
DATE
Unconscious
Dazed / Dizzy
Knocked out
Concussion
Headaches
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practices: #
Missed Games: #
Other
COMMENTS:
NECK
Strained Muscle
Sprained Ligament
Stretches
Pinches
Disk Injury
Dislocations
Burners / Stingers
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practices: #
Missed Games: #
Other
YES
NO
DATE
R
L
✔
COMMENTS:
12
CHEST WALL
Fractured Collar Bone
Sterno-Clavicular Joint Separation
Fractured / Bruised Ribs
Costalchondritis
Pneumothorax
Sternal Injury
Bruise
Pains
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practices: #
Missed Games: #
Other
COMMENTS:
MID BACK
YES
NO
DATE
R
L
YES
NO
DATE
R
L
YES
NO
DATE
R
L
Strained Muscle
Sprained Ligament
Nerve Pinches
Disk Injury
Spondylolisthesis
Scoliosis
Abnormal Kyphosis
Referred Pain
Numbness in Leg
Weakness in Leg
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practices: #
Missed Games: #
Other
COMMENTS:
LOWER BACK
Strained Muscle
Sprained Ligament
Nerve Pinches
----Continued On Next Page----
13
LOWER BACK --cont
YES
NO
DATE
R
L
R
L
Disk Injury
Sacroiliac Joint Disorder
Referred Pain
Pain Down Leg
Numbness in Leg
Weakness in Leg
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
SHOULDERS
YES
NO
DATE
Strained Muscle
Sprained Ligament
A-C Separations
Dislocations
Partial Dislocations
Shoulder Slips out of Place
Rotator Cuff Injury
Impingement
Tendinitis
Bursitis
Bruise
Injections
Pain with Overhead Activity
Arm Goes “Dead” After Trauma
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
14
UPPER ARMS & FOREARMS
Strained Muscle
Calcium Deposit
Casted
Numbness in Fingers
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
YES
NO
DATE
R
L
ELBOWS
YES
NO
DATE
R
L
WRISTS
YES
NO
DATE
R
L
Strained Muscle
Sprained Ligament
Bursitis
Dislocations
Joint Locking
Casted
Tendinitis
Bruise
Swelling
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
Strained Muscle
Sprained Ligament
Tendinitis
Dislocations
Casted
----Continued On Next Page---15
WRISTS -- Cont
YES
NO
DATE
R
L
YES
NO
DATE
R
L
YES
NO
DATE
R
L
Bruise
Cyst
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
HANDS
Strained Muscle
Sprained Ligament
Dislocations
Casted / Splinted
Bruise
Cyst
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
FINGERS / THUMBS
Strained Muscle
Sprained Ligament
Dislocation
Casted
Cyst
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
----Continued On Next Page----
16
FINGERS / THUMBS -- Cont
YES
NO
DATE
R
L
YES
NO
DATE
R
L
YES
NO
DATE
R
L
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
HIPS AND PELVIS
Strained Muscle
Sprained Ligament
Groin Pulls
Dislocations
Casted
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
THIGHS
Strained Muscle
Sprained Ligament
Quad Pulls
Hamstring Pulls
IT Band Syndrome
Calcium Deposits
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
17
KNEES
YES
NO
DATE
R
L
YES
NO
DATE
R
L
✔
✔
Strained Muscle
Sprained Ligament
Torn Ligaments
Torn Cartilage
Knee Cap Injury
Knee Cap Dislocation
Osgood Schlatter’s
Bursitis
Swelling
Locking
Giving Away
Sudden Weakness, Shifting
Wear Brace --- Kind?
Casted
Arthritis
Chondromalacia
Grinding
Tendinitis
Jumper’s Knee
Bruise
Injections
Pains
Pain with Stairs
Pain with Squats
Arthrograms
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
LOWER LEGS
Strained Muscle
Sprained Ligament
Shin Splints
Bursitis
Bruise
Injections
Painful – Tight Calf with Activity
Achilles Tendon Injury
Stress Fracture
Fractures
----Continued On Next Page----
18
LOWER LEGS -- Cont
YES
NO
DATE
R
L
ANKLES
YES
NO
DATE
R
L
FEET AND TOES
YES
NO
DATE
R
L
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
Strained Muscle
Sprained Ligament
Dislocations
Instability
Giving Out
Weakness
Dislocation
Casted / Splinted
Bruise
Injections
Pains
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
Strained Muscle
Sprained Ligament
Turf Toe
Plantar Fasciitis
Bunions
Dislocations
Casted / Splinted
Bruise
Injections
Fractures
X-rays, CT, MRI
Hospitalized
Surgery
Missed Practice: #
Missed Games: #
Other
COMMENTS:
✔
✔
19
YES NO
Have you had or do you have any other medical problems or injuries not listed on
this form?
Do you have any medical or health problems that you are currently receiving
medical treatment for?
Is there any reason that you are not able to participate in athletics?
Are there any additional health problems you would prefer to discuss privately
with our team physician?
IF ANY OF THE ABOVE QUESTIONS WERE ANSWERED YES, PLEASE COMMENT:
List any special protective equipment you require or would like to have provided:
The undersigned, here within,
A.
Understands that he/she must refrain from practice or play during medical treatments
until he/she is discharged from treatment or given a written permit by the attending
physician to resume participation.
B.
Understands and will abide by the Athletic Training Facility Guidelines.
C.
Understands that his/her having passed the physical examination does not necessarily
mean that he/she is physically qualified to engage in athletics, but only that the
examiner did not find a medical reason to disqualify him/her.
D.
Fully realizes the Cuesta College, San Luis Obispo, Department of Athletics cannot
be held responsible for any previous medical condition(s) that he/she might have.
E.
Understands permission to participate in intercollegiate athletics will not be granted
until all subsequent forms are completed and have successfully passed the physical
examination.
F.
Certifies that the answers to the health history questionnaire correct and true.
SIGNATURE:
DATE:
Upon completion of this Medical History form, it will be reviewed and signed by a certified
athletic trainer.
SIGNATURE:
DATE:
NATA Certified Athletic Trainer
20
Cuesta College Athletic Training
PO Box 8106 (HWY 1), San Luis Obispo, CA 93403-8106
(805) 546-3225 ph. • (805) 546-3158 Fax
Medical Consent
Directions:
I.
Please read carefully and sign the following consent forms. If you are
under 18 years of age, your parents must also sign.
II. If you choose to refuse to sign any of these consent forms, please write
“Refuse to Sign”, the date, and your signature. Notify your athletic
trainer.
III. This document will remain in effect for one year of signing and any
portion may be revoked at the discretion of the student-athlete by
notifying your athletic trainer.
Basic Content:
I.
Medical Consent: Allows athletic trainers and physicians to treat any
injury or illness you sustain while an athlete at Cuesta College, San Luis
Obispo.
II.
Release of Medical Information to the Media: Allows those listed to
release information concerning your injuries to the media.
III. Release of Information to Professional Sports: Allows those listed to
release any and all information concerning you, including medical
records and other items listed.
IV. Assumption of Risk: Acknowledges that all athletic activity affords a
certain amount of risk of injury and that you are aware of these risks and
the rules of your sport intended to minimize these risks.
V.
Blood Borne Pathogens: Acknowledges that exposure and transmission
of Blood Borne Pathogens is possible through athletics and that you are
willing to assume responsibility.
I. Medical Consent
I hereby grant permission to the Cuesta College, San Luis Obispo team
physician and/or their consulting physician to render to my son or daughter
or myself any treatment or medical or surgical care that they deem reasonably
necessary to the health and well being of the student-athlete.
21
I also hereby authorize the athletic training staff at Cuesta College, San Luis
Obispo who are under the guidance of the team physician, to render to my
son or daughter or myself any preventative, first aid, rehabilitative or
emergency treatment that they deem reasonably necessary to the health and
well being of the student-athlete.
Also, when necessary for executing such case, I grant permission for
hospitalization at an accredited hospital.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Date:
II.
Signature of Student-Athlete
Signature of Parent or Guardian
Authorization for release of Medical Information to the Media
This is to authorize Cuesta College, San Luis Obispo athletic training staff
and team physicians to release medical information of my son or daughter or
myself to the Cuesta Sports Information Department to provide media
outlets for any information concerning illness or injury relative to my past,
present, or future participation in intercollegiate athletics at Cuesta.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Date:
Signature of Student-Athlete
Signature of Parent or Guardian
22
III.
Authorization for Release of Medical Information for Employment in
Professional Sports
I,
, hereby authorize and request the Cuesta College
San Luis Obispo Athletic Training Department to supply to professional
athletic teams, their scouts, representative agents, athletic trainers, physicians,
or employees, any and all medical information concerning or having bearing
upon my participation in intercollegiate athletics at Cuesta College, San Luis
Obispo. This authorization shall include, but not limited, to any and all
information within their knowledge, or contained in any medical records under
their supervision or control concerning my physical condition, illness, injuries,
and any treatment, hospitalization, examinations, x-rays, and
to make such reports to such persons or organizations concerning myself that
they may request; and I hereby fully discharge all parties to whom this
authorization extends from any and all privilege in connection with the
disclosure of information included in this authorization.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Date:
IV.
Signature of Student-Athlete
Signature of Parent or Guardian
Assumption of Risk
Participation in sport requires an acceptance of risk of injury. Athletes
rightfully assume that those who are responsible for the conduct of sport
have taken reasonable precaution to minimize such risk and that peers
participating in the sport will not intentionally inflict injury upon them.
Attempts to legislate safety via rule books and equipment standards,
while helpful, is seldom entirely effective. Relying on officials to enforce
compliance with rules is also insufficient. Compliance with rules implies
respect on everyone’s part (student-athlete, coach, athletic trainer,
physician, and athletic director) for the intent and purpose of rules and
guidelines.
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I understand that by voluntarily participating in athletics at the collegiate
level, I am undertaking a non-controllable risk, which may result in injury,
illness or death.
I understand sickness and/or injuries are common in all athletics and that
Cuesta College, San Luis Obispo Athletics Department will provide the most
reasonable medical coverage in order to reduce the severity of such illness
and/or injury. The administration, coaches, and athletic trainers will equally
provide to each student-athlete, equipment required to produce the safest
possible intercollegiate athletic environment regardless of age, sex, race, or
religion.
I acknowledge and understand that the college is not providing transportation
and it is my responsibility to arrange for any transportation to and from the
activity. If the college is providing transportation but I do not use the
transportation, I am responsible to make my own transportation
arrangements and the college assumes no responsibility or liability of any
kind.
I have read the above assumption of risk statement. I understand that there
are certain inherent risks involved while participating in intercollegiate
athletics. I acknowledge the fact these risks exist and I am willing to assume
responsibility for such risks while participating at Cuesta College, San Luis
Obispo.
If the student-athlete is under 18 years of age, a parent or guardian
signature is required.
Date:
Date:
Signature of Student-Athlete
Signature of Parent or Guardian
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V.
Blood-Borne Pathogens and Intercollegiate Athletics
(Copyright, 1997, by the NCAA)
Blood-Borne pathogens are disease-causing microorganisms that can
be potentially transmitted through blood contact. The blood-borne
pathogens of concern include (but are not limited to) the hepatitis
virus (HBV) and the human immunodeficiency virus (HIV). Infection
with these viruses has increased throughout the last decade among all
portions of the general population. These diseases have potential for
catastrophic health consequences. Knowledge and awareness of
appropriate preventative strategies are essential for all members of
society, including student- athletes.
The particular blood-borne pathogens HBV and HIV are transmitted by
practicing risky unprotected sexual contact (heterosexual and
homosexual), direct contact with infected blood or blood components,
and prenatally from mother to baby. Experts have concurred that the risk
of transmission on the athletic field is minimal.
HBV is a blood-borne pathogen that can cause infection of the liver. Many
of those infected will range from no symptoms to a mild flu-like illness.
One third will have severe hepatitis, which cause the death of one percent
of that group. Currently, in the United States there are one
million chronic carriers of HBV. Chronic complications of HBV infections
include cirrhosis of the liver and liver cancer. The incidence of HBV in
student-athletes is presumably low, but those practicing risky behaviors
off the athletic field have an increased likelihood of infection (just as in
the case of HIV). An effective vaccine to prevent HBV is available and
recommended for all college students by the American College Health
Association.
The Acquired Immunodeficiency Syndrome (AIDS) is caused by HIV,
which infects cells of the immune system and other tissues such as the
brain. Some of those infected will remain asymptomatic for many years.
Others will more rapidly develop the manifestation of the HIV disease
(i.e. AIDS). Some experts believe virtually all persons infected with HIV
will eventually develop AIDS, which is fatal. In the United States there
are 40,000 to 50,000 newly infected persons each year. There are 1.5
million infected persons in the United States. The risk of infection is
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increased by having unprotected sexual intercourse and sharing IV
needles. Currently, there is no vaccination available to prevent HIV.
HBV is a more “sturdy/durable” virus than HIV and is more highly
concentrated in blood. HBV is more likely to be transmitted by exposure
to infected blood, particularly with needle-stick exposure, but also
exposure to open wounds and mucus membranes. The risk of
transmission for either HBV or HIV is considered minimal; however,
most experts agree that the specific epidemiological and biologic
characteristics of the viruses make them a realistic concern for
transmission in sports with sustained close physical contact.
Cuesta College, San Luis Obispo athletic training staff acknowledges the
risks and utilizes Universal Precautions as recommended by the Center
for Disease Control, OSHA and the NCAA Sports Medicine Handbook to
minimize the risk of blood-borne pathogen exposure and transmission on
the context of athletic events and treatment guidelines for the health care
of student-athletes.
I have carefully read and fully understand the risk of bloodborne pathogens exposure and transmission.
If the student-athlete is under 18 years of age, a parent or
guardian signature is required.
Date:
Date:
Signature of Student-Athlete
Signature of Parent or Guardian
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NOT VALID UNLESS STAMPED * * * * * * * * * * * * * * * NOT VALID UNLESS STAMPED
Cuesta College Athletics
Health Screening
Name
Address
Date of Examination
Sport(s)
Local/Cell Phone
Parent Phone
Birth Date
Social Security Number
Do you have a history of:
HEAD INJURY/UNCONSCIOUSNESS
SHOULDER INJURY
KNEE INJURY
ANKLE OR FOOT INJURY
ELBOW, WRIST OR HAND INJURY
BACK INJURY
HIP INJURY
HERNIA
MISSING ONE OF A PAIRED ORGAN
DIABETES OR EPILEPSY
ALLERGIES
ASTHMA
SURGERY
ACTIVITY RELATED
DIZZINESS/FAINTING
FAMILY HISTORY OF NONTRAUMATIC
SUDDEN DEATH
LIST MEDICINES CURRENTLY
TAKING
YES NO DATE
IF YES, PLEASE EXPLAIN
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
The undersigned, herewith, understands that having passed the health screening does not necessarily mean that he or she is
physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify him/her at the
time of the examination.
Do you know of, or do you believe there is, any health reason why you should not participate in athletics at this time?
YES
NO
(circle one)
I certify that the answers to the questions above are correct and true.
Date
Athlete sign here:
***To Be Completed by Physician’s Office Only***
Height
Weight
BP
Pulse
Musculoskeletal:
Vision:
Right
Left
Corrective lens/contacts?
H.E.E.N.T.
Lungs
ABD
Heart
Teeth/bridge/false teeth?
Remarks:
Physicians Signature:
M.D. or D.O. only
Physicians stamp or medical license #:
***TO BE COMPLETED BY ATHLETIC TRAINER***
Name:
Sport:
Date:
Balance Error Scoring System (BESS)
Balance Error Scoring System –
Types of Errors
1. Hands lifted off iliac crest
2. Opening eyes
3. Step, stumble, or fall
4. Moving hip into > 30 degrees abduction
5. Lifting forefoot or heel
6. Remaining out of test position >5 sec
The BESS is calculated by adding one
error point for each error during the 6
20-second tests.
Which foot was tested: 0 Left 0 Right
(i.e. which is the non-dominant foot)
SCORE CARD:
(# errors)
Double Leg Stance
(feet together)
Single Leg Stance
(non-dominant foot)
Tandem Stance
(non-dom foot in back)
Total Scores:
FIRM
Surface