Please print out the entire physical exam form package:
This package includes
five pages:
1.
Physical History
2.
Physical Evaluation
3.
Contact Information/Insurance Status
4.
Acknowledgement of Risk
5.
Athletic Insurance Coverage
6.
Cardiac Screen
All forms should be printed legibly in black or blue ink only.
After printing the forms, please complete pages one and two of the
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 three, the
Report of Health Evaluation. Sickle cell trait result is an NCAA requirement, so if they have not already done so, they must take the test and provide a written copy of the result. The doctor can just write it into the exam form.
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 Athletic 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 gray shaded “signature” box, please make sure that the appropriate person signs it.
Please complete the 14 Point Cardiac Screening form by answering “YES” or “NO” where appropriate including any details that you are aware of.
You will need to discuss any of these points with the examining physician at the time of your physical. Please attach this form to your physical package.
Turn in all of the completed and appropriately signed forms to the Sports Medicine Staff when you arrive on campus. All five forms must be checked and approved by the Sports Medicine Staff prior to any athletic practice or participation. Do not attempt to mail in the forms, unless you keep a copy for your files. They could get lost in the mail.
------------
**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)-665-2233 or Alfred Castillo by email at alfred.castillo@utrgv.edu.
