New Student-Athlete Checklist

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Karen Wilkerson
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New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Verify Primary Insurance(see attached instructions) Complete Athletic Training Forms online (see attached

1 New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Verify Primary Insurance(see attached instructions) Complete Athletic Training Forms online (see attached instructions) Should you have any questions or require further information, please do not hesitate to contact us at or by . Isaac Perry, LAT, ATC Head Athletic Trainer Jake Decker, LAT, ATC Assistant Athletic Trainer

2 PRE-PARTICIPATION PHYSICAL EVALUATION FOR ATHLETICS DATE OF EXAM: NAME: SPORT: Sex: [ ] M [ ] F Age: Date of Birth: PHONE: Class Standing: [ ] Freshman [ ] Sophomore [ ] Junior [ ] Senior [ ] Yes [ ] No Have you had an illness or injury in the past year? [ ] Yes [ ] No Do you, or have you had an ongoing or chronic illness or injury? [ ] Yes [ ] No Have you ever been hospitalized overnight? [ ] Yes [ ] No Do you take any prescription or over-the-counter medications (including inhalers)? [ ] Yes [ ] No Are you taking any herbal medications or supplements (e.g. to gain or lose weight or to improve performance)? [ ] Yes [ ] No Do you have any allergies (for example, to pollen, medicine, foods, or stinging insects)? [ ] Yes [ ] No Have you ever passed out during or after exercise? [ ] Yes [ ] No Have you ever been dizzy during or after exercise? [ ] Yes [ ] No Have you ever had chest pain during or after exercise? [ ] Yes [ ] No Do you get tired more quickly or have a harder time breathing than your friends during exercise? [ ] Yes [ ] No Have you ever had racing of your heart or skipped heart beats? [ ] Yes [ ] No Have you ever been restricted from participation in sports in the past? [ ] Yes [ ] No Have you ever had prior testing for the heart (EKG, electrocardiogram, etc.)? [ ] Yes [ ] No Have you ever had high blood pressure? [ ] Yes [ ] No Have you ever been told you have a heart murmur? [ ] Yes [ ] No Has any family member or relative died of heart problems or sudden death before age 50? [ ] Yes [ ] No Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, or hives)? [ ] Yes [ ] No Have you ever had a head injury or concussion (knocked out or confused)? [ ] Yes [ ] No Have you ever had a seizure? [ ] Yes [ ] No Do you have frequent or severe headaches? [ ] Yes [ ] No Have you ever had a stinger, burner, or pinched nerve? [ ] Yes [ ] No Have you ever become ill from exercising in the heat? [ ] Yes [ ] No Do you ever cough, wheeze, or have trouble breathing during or after exercise? [ ] Yes [ ] No Do you have any special braces, retainers, orthotics, or other devices? [ ] Yes [ ] No Have you had problems with your eyes or vision? [ ] Yes [ ] No Do you have any trouble hearing? [ ] Yes [ ] No Have you broken or fractured any bones, or dislocated any joints? [ ] Yes [ ] No Have you had any problems with pain or swelling in muscles, tendons, bones, or joints? [ ] Yes [ ] No Do you want to weigh more or less than you do now? [ ] Yes [ ] No Do you lose weight regularly to meet weight requirements for your sport(s)? [ ] Yes [ ] No Do you have a single eye or kidney? [ ] Yes [ ] No Do you smoke or chew tobacco? [ ] Yes [ ] No Do you regularly consume alcohol? [ ] Yes [ ] No Do you use marijuana or any other substances? [ ] Yes [ ] No Do you have any health concerns about trying out for this sport? [ ] Yes [ ] No Do you often have trouble sleeping? [ ] Yes [ ] No Do you wish you had more energy most days of the week? [ ] Yes [ ] No Do you think about things over and over again even after the situation is passed? [ ] Yes [ ] No Do you feel anxious and nervous most of the time? [ ] Yes [ ] No Do you feel sad or depressed? [ ] Yes [ ] No Do you struggle with being confident? [ ] Yes [ ] No Do you have trouble feeling hopeful about the future? [ ] Yes [ ] No Do you have a hard time managing your emotions (frustration, anger, impatience)? [ ] Yes [ ] No Do you/have you had feelings of hurting yourself of others? [ ] Yes [ ] No Do you have regular menstrual periods? (FEMALES ONLY) I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. I authorize the release of this physical exam to the Central Washington University Athletic Department. Athlete s Signature: Date:

3 Explain Yes answers below: Height Weight Temp. Pulse BP Vision Corrected Glasses [ ] L20/ R20/ L20/ R20/ Contacts [ ] Current Meds. Allergies (describe findings below, referring to item number) Normal Abnormal [ ] 1. Head [ ] [ ] 2. Eyes (pupils), ENT [ ] [ ] 3. Teeth [ ] [ ] 4. Chest [ ] [ ] 5. Lungs [ ] [ ] 6. Heart [ ] [ ] 7. Abdomen [ ] [ ] 8. Genitalia (male only) [ ] [ ] 9. Neurologic [ ] [ ] 10. Skin [ ] [ ] 11. Spine, back, neck [ ] [ ] 12. Shoulders, upper extremities [ ] [ ] 13. Lower extremities [ ] [ ] 14. HCT [ ] [ ] 15. UA [ ] [ ] Yes [ ] No Sports participation approved [ ] Yes [ ] No Approved with the following recommendation(s): Provider Name (print/type): Address: Provider Signature: Date: 3/15/2016

4 Important insurance information All of our student-athletes are required to carry primary insurance in order to practice and compete in their sport. It is important to verify the information below with your insurance company prior to arriving on campus. This can usually be done online using the find a provider tool, or by calling the customer service number on the back of the card. This is especially important for out of state athletes as some plans can have regional coverage, and out of state coverage has to be requested or added. If you have questions feel free to call the Athletic Training office at (509) I have verified with my insurance company that my plan provides (please initial below): o o o Health insurance coverage in Kittitas, Yakima County and Washington State. In Network - Orthopedic doctors in the Ellensburg/Yakima, Washington area. This is for doctor s visits, X-rays, MRIs, Surgeries Our specific team doctor is- Dr. Richard Roux out of Orthopedics Northwest Out of state and/or out of area coverage, if I am injured at an away game or practice in another stat e. Health insurance coverage for intercollegiate sports-related injury or illness. I understand that I cannot participate for any intercollegiate sport without acceptable health insurance coverage - there are NO exceptions! I will continue to maintain a health insurance plan for the duration of my participation in intercollegiate sports. I understand that it is my responsibility, and that of my parent and/or guardian, to immediately report discontinued coverage or any change in plans to CWU athletic trainers by completing a new Athletic Insurance Questionnaire and submitting a new insurance ID card. I have read and agreed to comply with the provisions of the Acknowledgement of Insurance Requirements Parent/Guardian Signature Student-Athlete Signature (Signature required if insurance holder) The athletic department does carry a secondary insurance policy that can help cover our athletes in the case of injury. However, our policy carries a deductible of $7,500. It is our intention that this deductible will be met by the primary insurance company. If any portion of the deductible is not satisfied by the primary insurance company this amount will be the responsibility of the student-athlete and/or parent/ guardian. Additional information can be found on the ATS paperwork done during the next section

Step by Step Instructions for Athlete Portal Some tips that should make the process easier -Use a mouse to fill out the online forms. Don t use a trackpad. The mouse is necessary to sign the forms.

-If you have any trouble please contact the Athletic Training Staff and we can help you. 1. Type cwu2.atsusers.com in web address box a. The database should say ATSCWU b.

(Example-if you are going to play football and run track, you need to add both teams). b. Complete all the information in the yellow boxes. The information in the yellow boxes is mandatory.

5 Step by Step Instructions for Athlete Portal Some tips that should make the process easier -Use a mouse to fill out the online forms. Don t use a trackpad. The mouse is necessary to sign the forms. You can also use a stylus or your finger to sign on a touchscreen device. -Use Chrome, Mozilla or Safari to access the Athlete Portal. Internet Explorer does not work with system. -If you have any trouble please contact the Athletic Training Staff and we can help you. 1. Type cwu2.atsusers.com in web address box a. The database should say ATSCWU b. For Athlete ID : Enter- new c. For Password: Enter- new 2. Athlete Information Page-General a. Select your team/teams from the drop down menu. (Example-if you are going to play football and run track, you need to add both teams). b. Complete all the information in the yellow boxes. The information in the yellow boxes is mandatory. Please fill out all information as completely as possible. c. Enter an Athlete ID and password that is unique to you. Using something like you CWU log in can help you remember. This is used to log in and update info as needed d. If you have any medical alert or allergies please fill out these sections. For example this includes ADHD, Diabetes or Asthma. If you have no medical alert or allergies please type none. Can use drop down options too. e. Please fill out any and all current medications. Current medications could include birth control, ADD medications, other medications including over the counter medications which are taken on a daily basis. It is important that we have a list of current medications in case of emergency or need for further medical care. If you are not taking any medications, please type none.

If name of your insurance company is not available on the drop down menu you can add the information for the insurance company d.

6 3. Insurance a. Click on insurance tab i. If you don t have primary health insurance, please click the box that says No Primary Insurance. 1. It is a requirement that you have primary health insurance by the time you report for your sport. You cannot participate in any practice or weight/ conditioning session without insurance. b. Complete all of the yellow boxes c. If name of your insurance company is not available on the drop down menu you can add the information for the insurance company d. Please bring your card or copy of card with you to campus during athlete check in. We will take pictures of it for you. You do not need to upload a copy of your insurance card online. C/S/Z=City, State, Zip Athlete s Relationship to Insured = Child if the insurance is through your parents. 4. Contacts-Emergency Contacts a. Click on contact tab i. Please add someone you want us to contact in case of an emergency. b. Complete all of the yellow boxes 5. Click Save Athlete Information Button-More Tabs will now appear

6. Athlete Forms (Do not skip!) a. Click on Form Tab b. Click on the drop down menu titled Form Name i. You must complete every form listed under this drop down menu c.

After reading all the information on this form, and answering the questions when required go down to the athlete/student signature box. i. Using a mouse, stylus or finger: sign your name ii.

You should see a box that says Save Complete. Do not move on to next form until you see this. g.

7 6. Athlete Forms (Do not skip!) a. Click on Form Tab b. Click on the drop down menu titled Form Name i. You must complete every form listed under this drop down menu c. Select Form from the drop down menu titled Form Name d. Click the New Button e. After reading all the information on this form, and answering the questions when required go down to the athlete/student signature box. i. Using a mouse, stylus or finger: sign your name ii. Type your name in the signed by box and click on the Sign button iii. If you are a minor: repeat this process for parent/guardian signature box. f. Click save when finished. You should see a box that says Save Complete. Do not move on to next form until you see this. g. On the SICKLE CELL TRAIT form, please note that only one Yes selection should be made, the other options should be marked No Also be aware that if Yes is selected for either of the first two options Athlete cannot practice without results 7. E-files (as needed) a. Click on the E-file Tab b. The physical forms are located here. c. Please follow the instructions listed with the correct form. d. Once the physical is completed by a Doctor it should be brought to campus during athlete check in. It does not need to be uploaded online

New Student-Athlete Checklist

New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Complete Athletic Training Forms online (see attached instructions) BESS/SCAT/ImPact Test (when arrive) Should you have