Department of Athletic Training

Returning Athlete Questionnaire

Name _______________________ Date of Birth____________________

Sport________________________ SSN __________________________

All Questions must be answered and the Questionnaire Signed

1. During the Past 12 months have you been seen by a Medical Doctor for a significant illness (including mental)? Yes____ No____ *If yes, provide the following information

A. Illness___________________ Date seen by MD_________________

B. Name and phone number of MD

__________________________________

__________________________________

__________________________________

C. Athletic Trainers Comments: ______________________________________

______________________________________

2. During the past 12 months have you had a serious injury and/or surgery?

Yes _____ No _____ *If yes, provide the following information

A. Injury/Surgery __________________________________________________

Date __________________

B. Name and phone number of MD

_______________________________

_______________________________

_______________________________

C. Athletic Trainers Comments: _______________________________________

_______________________________________

3. Do you have any medical condition or problem of any type for which you want or need to see a Doctor or Athletic Trainer for? Yes_____ No_____

A. Condition: ____________________________________________________

B. Who would you like to see:_______________________________________

Department of Athletic Training

THE UNDERSIGNED ATHLETE HEREWITH:

1. Certifies that the answers to the questions are true and correct.

2. Understands that any medical expense incurred while participating in athletics at Montana State University Northern are his/her responsibility. Montana State University does not carry an excess insurance policy. Students are required to have and show proof of a primary medical insurance policy.

3. Understands that participation in sports requires an acceptance of risk of injury. (Athletes rightfully assume that those who are responsible for the conduct of sports has taken reasonable precautions to minimize such risks and that their peers participating in the sport will not intentionally inflict injury upon them.

4. Understands that the periodic analyses of injury patterns leads to refinements in the rules and other safety decisions. However, to legislate safety via a rule book and equipment standards, while often necessary, seldom is effective by itself; and to rely on officials to enforce compliance with the rule book is as insufficient as to rely on warning labels to produce compliance with safety guidelines. “Compliance” means respect on everyone’s part for the intent and purposes of a rule or guideline.

5. Understands that he/she must refrain from practice or play while ill or injured, whether or not receiving medical treatment, and during medical treatment until he/she is discharged from treatment or is given permission by the doctor or athletic trainer to restart participation despite continuing treatment.

6. Understands that having passed the physical examination does not necessarily mean that he/she is physically qualified t engage in athletics, but only that the evaluator did not find a medical reason to disqualify him/her at the time of evaluation.

7. Authorizes any hospital, physician or other person attending or examining he/she to disclose when requested to do so by Montana State University Northern, its insurer, or their representatives any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment and copies of all hospital or medical records. A photocopy of this authorization shall be considered as valid as the original.

ATHLETES SIGNATURE__________________________ DATE ______________

ATHLETIC TRAINER SIGNATURE________________ DATE ______________

OK FOR PARTICIPATION ______ NOT OK FOR PARTICIPATION _____