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INSTRUCTIONS FOR 2013-2014 RETURNING STUDENT MEDICAL FORM

Page 1: Fill out Personal Information in its entirety, including an email that you check regularly, as well
as a current cell phone number. Make sure you provide two Emergency Contacts. Complete the Insurance
Information, and in addition to the information, make sure you include COPIES of your insurance cards. Sign
and date page 1 and have a parent/guardian co-sign if you are under 18 years of age.

Page 2: Read each section and sign and date each section. Have parent/guardian sign if under 18.

Pages 3-7: Answer yes or no to EACH question. For any yes answers, provide as much detail in the
explanation area as possible. Include any additional documentation from previous injuries, surgeries, or
physician visits.

Page 8: Read Mouth guards and Dental, Mouth and Jaw Injuries, sign and date. Below shaded area
initial where indicated, then sign and date. Have parent/guardian co-sign if under 18.

Page 9: Complete Concussion Disclosure and sign and date. Read the information on Sickle Cell
Testing.


Bring this completed form to the Athletic Training Room, on the B2 level of the West Building at the date and
time given to you by your coach for the completion of the Medical Clearance Process.


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Please Print and Use Pen Only. Do Not Leave Blanks.





























Sports Medicine
Phone: (212)650-3131
Fax: (212) 650-3161
2013-2014
RETURNING
Student Medical
Form

INSURANCE INFORMATION
**A front and back copy of all insurance cards MUST be attached (health, dental, prescription, etc)**
Do you have health/dental insurance? (please circle one) Yes No (if no, skip to bottom and sign)
I am insured through (please check all that apply): myself spouse mother father guardian

Health Insurance Dental (if different) or other Health Insurance
Policy Holder Information
________________________________________ Name _______________________________________
(Last Name, First Name) (Last Name, First Name)
________________________________________ Date of Birth _______________________________________
(mm/dd/yyyy) (mm/dd/yyyy)
________________________________________ Address _______________________________________
________________________________________ City, State, Zip _______________________________________
Insurance Company Information
________________________________________ Insurance Company Name _______________________________________
________________________________________ Address _______________________________________
________________________________________ Group # _______________________________________
________________________________________ Policy/Member # _______________________________________
________________________________________ Phone # _______________________________________
HMO PPO POS (please check all that apply) HMO PPO POS
Pre-authorization Required Referral Required Pre-authorization Required Referral Required

I hereby certify that the information provided above is true, complete, and correct to the best of my knowledge. I understand that if the above information has
been fraudulently misrepresented, my claim will be denied, I risk losing eligibility to participate in intercollegiate sports, and I may face prosecution.(___ )Initial
I understand that Hunter Colleges Intercollegiate Sports (ICS) insurance is in excess or secondary to any other collectible group insurance benefits. It is my
responsibility to first file a claim for benefits with my primary insurance company. After they have paid all available benefits, Hunter Colleges ICS insurance
company will consider remaining amounts based on USUAL and CUSTOMARY charges. I understand that I must send copies of the Explanantion of Benefits
(EOB) from my insurance company and itemized medical bills including descriptions of medical services provided to my Athletic Trainer in order to receive
benefits from Hunter Colleges ICS insurance. I understand that only supervised official practices and competition are covered under Hunter Colleges ICS
insurance. I also understand that illnesses, pre-existing conditions, or chronic conditions are not covered by Hunter Colleges ICS insurance. I have read and
understand the current Insurance Coverage and Procedures portion in my Hunter College Student-Athlete Handbook. I understand that it is my responsibility to
notify the appropriate departments in a timely fashion should any of the above information change.
_____________________________________________________________________________________
Signature of Student-Athlete Date

________________________________________________________________________________________________________________________________
Signature of Parent/Guardian (if under 18 yrs old or parent/guardian is policy holder of primary insurance) Date

PERSONAL INFORMATION
Name:__________________________________________ Todays Date:_____________________
(Last Name, First Name) (mm/dd/yyyy)
Date of Birth: _______/_______/_________ Age: _______ Grade: FR / SO / JR / SR / 5
th
yr
(mm/dd/yyyy)
Sport: _____________________________ Year of Sport Participatin at Hunter: 1
st
/ 2
nd
/ 3
rd
/ 4
th
/ 5
th

Permanent Address Local Address
Street:_____________________________________ Street: __________________________________
City: ____________________State:_____Zip:______ City:__________________State:______Zip:_______

Home Phone: ________-_________-__________ Cell Phone: _______-________-_________
Email (one that you check):___________________________________________________________________
EMERGENCY CONTACT
1. Name: __________________________________________ Relationship: __________________
Home Phone:_____-_____-______ Cell Phone:____-____-_____ Work Phone: _____-_____-_______
2. Name: __________________________________________ Relationship: __________________
Home Phone:_____-_____-______ Cell Phone:____-____-_____ Work Phone: _____-_____-_______
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Please read thoroughly prior to signing.











































2013-2014
RETURNING Student
Information
Sports Medicine
Phone: (212)650-3131
Fax: (212) 650-3161

Name:__________________________________________ Date of Birth:_____________________
(Last Name, First Name) (mm/dd/yyyy)

Acknowledgement and Assumption of Risk
I understand there are inherent risks with participation in intercollegiate athletics. I am fully aware that my participation may
result in minor, career ending, or life threatening injury or illness, permanent physical or mental impairment, or even death. I
understand it is my responsibility to adhere to all the rules and regulations of my chosen sport. I understand infraction of these
rules and regulations by myself, my opponent, or my teammate may result in injury. I understand failure to properly use
equipment or to follow safety protocols could also result in injury. I understand Hunter College, its personnel, CUNY and the
City of New York can not be held responsible for such injuries as well as any pre-existing medical condition.
I understand it is my responsibility to cease activity and report all illnesses and injuries to my athletic trainer within 24 hours of
its occurrence. I understand I must follow treatment protocols set forth by my athletic trainer and may not return to participation
until given permission by Hunter Colleges Sports Medicine staff (including but not limited to the Athletic Trainer and Team
Physicians.)
I am fully aware that having passed the physical examination DOES NOT necessarily mean that I am physically qualified to
participate in intercollegiate athletics at Hunter College, but only that the evaluator did not find a medical reason to disqualify
me at the time of physical examination.
By signing below, I voluntarily agree to the above statements, as well as acknowledge and assume responsibility to any and all
risks associated with my participation in intercollegiate athletics while at Hunter College; hereby releasing Hunter College, its
personnel, CUNY and the City of New York from any and all liability arising from my voluntary participation in athletics.
_____________________________________________________________________________________
Signature of Student-Athlete Date

________________________________________________________________________________________________________________________________
Signature of Parent/Guardian (if under 18 yrs old) Date

Authorization, Agreement, and Consent to Treatment
I understand injury or illness can result from my participation in intercollegiate athletics. I hereby authorize Hunter College
Sports Medicine staff to obtain for me any medical treatment and/or care deemed necessary in the event of such injury or illness.
I consent to the administration of said medical or surgical treatment recommended by a licensed health care provider as seen
necessary to my well being and health. I freely give my permission for hospitalization at an accredited hospital in the event that
it is required.
A photocopy or facsimile of this authorization is effective and valid as the original.
_____________________________________________________________________________________
Signature of Student-Athlete Date

________________________________________________________________________________________________________________________________
Signature of Parent/Guardian (if under 18 yrs old) Date
Information Release Authorization
I hereby authorize Hunter College Sports Medicine Staff and medical personnel to disclose and discuss with my parents/legal
guardians, Hunter College coaches, Hunter College athletic administrators (including but not limited to the Athletic Director and
Associate Athletic Director), medical personnel and insurance carrier/claims adminstrator, information about my injury, health
care, and health status for the purposes of advising on the status of my health or injury when necessary and to access insurance
coverage under any policy that may cover my medical treatment costs.
I am further authorizing Hunter College Sports Medicine Staff and medical personnel to obtain medical information and records
from all my past and present health care providers.
I understand that I may revoke this release at any time by notifying the Hunter College Sports Medicine staff in writing. This
authorization is valid until such written revocation is received.
A photocopy or facsimile of this authorization is effective and valid as the original.
_____________________________________________________________________________________
Signature of Student-Athlete Date

________________________________________________________________________________________________________________________________
Signature of Parent/Guardian (if under 18 yrs old) Date

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Please Print and Use Pen Only.

Medical History

Do you/ Have you ever had any of the following: (if yes, please explain in the space provided)
HEAD/NERVOUS SYSTEM Yes No Explain (if yes)
Headache
Migraine
Seizures/convulsions
Dizzy spells/fainting
Insomnia
Recurrent anxiety
Excessive nervousness
Recurrent depression
Neuromuscular disorder
EYES/EARS/NOSE/THROAT Yes No Explain (if yes)
Wear glasses/contact lenses
Blindness
Color blindness
Eye injury/disease
Double vision
Deafness/hearing aid
Perforated ear drum
Repeated ear infections
Repeated nose bleeds
Frequent sore throats
Tonsils/adenoids removed
Sinus Trouble
Swollen glands
Thyroid Problem/disease
DENTAL Yes No Explain (if yes)
Poor Teeth/Toothaches
Missing Tooth/ Tooth injury
Bleeding Gums
Gum disease
Bridges/braces/plates
HEART/LUNGS Yes No Explain (if yes)
High cholesterol
High blood pressure
Heart murmur
Palpitations
Shortness of breath
Chest pain
Asthma/wheezing
Chronic cough
Pneumonia
Pleurisy
Bronchitis
2013-2014
RETURNING
Student
Information
Sports Medicine
Phone: (212)650-3131
Fax: (212) 650-3161
4
Do you smoke?
Chest pain, dizziness, fainting w/ exercise
SKIN Yes No Explain (if yes)
Acne
Fungal/Viral/Bacterial infection
Other skin diseases
BLOOD Yes No Explain (if yes)
Anemia
Abnormal Bruising
Abnormal Bleeding
Sickle cell disease/trait
DIGESTIVE TRACT Yes No Explain (if yes)
Ulcers
Chronic abdominal pain
Diarrhea, chronic/current
Colitis/ileitis
Irritable bowl syndrome
Gallbladder disease/injury
Gallstones
URINARY Yes No Explain (if yes)
Frequent urination
Painful urination
Blood in urine
Recurrent urinary infection
Kidney infection
Kidney stone
PSYCHOLOGICAL Yes No Explain (if yes)
Experience frequent
anxiety/depression?
Receive(d) treatment for
anxiety/depression?
Receive(d) treatment for
personality/emotional disorder?
Receive(d) treatment for substance
abuse?
Experience trouble falling
asleep/staying asleep?
FEMALES ONLY Yes No Explain (if yes)
Do you have irregular periods?
Have you ever stopped menstruating?
Do you have heavy bleeding during
your periods?
Severe cramps/pain during your
periods?
Take medications during your periods?
Do you have both of your ovaries?
MALES ONLY Yes No Explain (if yes)
Do you have a history of testicular
torsion?
Painful urination?
Other testicular pathology?
Are both of your testicles present?
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OTHER Yes No Explain (if yes)
Adverse reaction to ice treatments
Cancer/tumor
Chicken pox
Cysts
Dehydration
Diabetes
Easting disorder
Heat illness/exhaustion
Hepatitis/liver disease
Hospitalization
Malaria
Marfan's syndrome
Meningitis
Mononucleosis
MRSA/Staphylococcus infection
Mumps/Measles/Rubella
Muscle cramps due to heat
Rheumatic fever
Sudden weight change
Tuberculosis/ Postive skin test
Venereal disease
Whooping cough

GENERAL INFORMATION
1. Are you currently under the care of a physician? If yes, for what?______________________________________
_________________________________________________________________________________________
2. May the Hunter College Medical staff contact this physician?
Physician's Name: ________________________
Address: _______________________________
City/ State/ Zip: __________________________
Phone Number: (______)___________________

3. List all allergies.
a. _______________________________ c.______________________________
b._______________________________ d.______________________________

Have you ever needed the use of an Epipen? YES NO if YES, when? (date)_____________________

4. List all prescription medication currently taken. Explain reason for medication.
a. _______________________________ c.______________________________
b._______________________________ d.______________________________




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ADD/ADHD NCAA REGULATION REQUIRMENTS

The NCAA now requires athletes who are taking medications for ADD and ADHD to provide specific
documentation to athletic departments.
As a student athlete we ask that you provide the athletic training staff with the following information:
1) A record of the ADD/ADHD evaluation
2) A record of the diagnosis of ADD/ADHD
3) A history of treatment
4) A copy of the most recent prescription
Having this information in your file will help prevent any problems or failure in the event of a drug test at
an NCAA event.


Injury History

HEAD/NECK Yes No Explain (if yes)
Diagnosed concussion/head injury
If yes: How many times? _______________________
Any loss of consciousness or amnesia? _________________________________
How long to make a complete recovery? _________________________________
When was your last concussion? ___________________________________
Fractured skull
Fractured nose/jaw
"Stinger"/ "Burner"
Numbness/tingling in your arms and hands
Disc Injury
Dislocation/ Fractures
Sprain/Strain
TORSO/SPINE Yes No Explain (if yes)
Fractured clavicle, sternum, rib(s)
Spinal dislocation/fracture
Sprain/Strain
Scoliosis
Disc Injury
Numbness/tingling in your buttocks, legs, feet
Pain/burning in your buttocks, legs, feet
Pain while weight training
Hernia
Have all functioning organs?
UPPER EXTREMITY
Shoulder: Yes No Explain (if yes)
Dislocation/subluxation
AC separation/sprain/strain
Grinding or Popping
Surgery
Elbow/forearm: Yes No Explain (if yes)
Fracture/Dislocation
Sprain/strain/bursitis
Surgery
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Wrist/hand/fingers: Yes No Explain (if yes)
Fracture/dislocation
Sprain/strain/bursitis
Surgery
LOWER EXTREMITY
Thigh, Hip, & Pelvis: Yes No Explain (if yes)
Fracture/stress fractures
Dislocation/subluxation
Strain (hamstring/groin/quad)
Sprain
Bursitis
Hip pointer
Grinding or popping
Surgery
Knee: Yes No Explain (if yes)
Sprain/strain/tendinitis/bursitis
Torn ligaments
Meniscus/cartilage injury
Patella (kneecap) injury
Chondromalacia
Osgood Schlatter's
Swelling/grinding/locking/giving way
Surgery
Lower leg: Yes No Explain (if yes)
Shin splints
Fracture/stress fractures
Achilles injury
Compartment syndrome
Ankle: Yes No Explain (if yes)
Sprain/strain/tendinitis
Torn ligaments
Dislocation/fracture
Surgery
Pain/swelling/stiffness/instability
Foot/toes: Yes No Explain (if yes)
Sprain
Turf toe
Dislocation
Fracture/stress fractures
Pes planus (flat feet)/Pes Cavus (high arch)
If yes: Do you wear orthotics?
Plantar faciitis
Surgery






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Please read thoroughly prior to signing.














































Mouthguards and Dental, Mouth, and Jaw Injuries
Hunter Colleges Intercollegiate Sports (ICS) insurance coverage and claim process for accidental dental,
mouth, and jaw injuries is similar to that of medical injuries and is also only during a sanctioned supervised
practice/competition. Pre-existing dental, mouth, and jaw conditions are not covered. Claims must first be filed
with the student-athletes primary insurance by the student-athlete. After the primary insurance has paid all
available benefits, Hunter Colleges ICS insurance company will consider remaining amounts based on
USUAL and CUSTOMARY charges. In order to receive benefits from Hunter Colleges ICS insurance,
original copies of the Explanation of Benefits (EOB) from the primary insurance company and itemized
medical bills including descriptions of medical services provided must be submitted to Hunter Colleges
athletic trainer as they are received. It is understood that student-athletes participating in basketball, field
events, soccer, softball, volleyball, and wrestling are provided with mouthguards. Student-athletes
participating in these sports must be wearing the mouthguard or one that has been approved by the athletic
trainer at the time of injury to qualify for coverage.
By signing below, I certify that I have read and understand the above stated policy and agree to comply with all of its provisions.
________________________________________________________________________________________
Signature of Student-Athlete Date

____________________________________________________________________________________________________________________________________
Signature of Parent/Guardian (if under 18 yrs old or parent/guardian is policy holder of primary insurance) Date



DO NOT WRITE IN THIS SPACE. Hunter College Athletic Staff ONLY.
(Check all that apply.)
M/W Basketball M/W Field Soccer Softball M/W Volleyball Wrestling
M/W Cross Country/Track M/W Fencing Swimming and Diving M/W Tennis
Mouthguard has been issued to student-athlete. Mouthguard has NOT been issued to student-athlete.
Student-Athlete has been approved by the athletic trainer to use their own mouthguard. (____) ATC initials
_______________________________________________________________________________________
(Athletic Staff Name/Title) (Date)

I acknowledge the medical history information provided above is true, complete, and correct to the best of my knowledge. I
understand that if the above information has been fraudulently misrepresented, medical and accidental insurance coverage will be
jeopardized, I risk losing eligibility to participate in intercollegiate sports, and I may face prosecution. (_____) I nitial
I fully understand that it is my responsibility to review current NCAA information on Banned Substances and the Drug Testing
program. I am aware that this information is available at www.ncaa.org/drugtesting. (_____) I nitial
I understand that I must contact my athletic trainer at (212)650-3131 if I am taking or am thinking about taking a dietary
supplement. I am aware that dietary supplements are not well regulated and may contain banned substances. I understand that taking
dietary supplements could result in a positive drug test and result in loss of eligibility. (_____) I nitial
I understand certain prescribed medications may also contain banned substances. I understand that I must contact my athletic trainer
if I am prescribed a medication by my physician prior to consumption. I understand that NCAA allows exceptions for certain
medical conditions and medications, for which additional information is available at www.ncaa.org/drugtesting. I understand that in
order to pursue these exceptions, I must work with my athletic trainer in ensuring all medical history and information is documented
properly. I understand that should I test positive for a banned substance and I do have have sufficient medical documentation, I will
lose my eligibility. (_____) I nitial
For athletes participating in basketball, field events, soccer, softball, volleyball, and wrestling only: I have been issued a
mouthguard and I understand that is my responsibility to use issued mouthguard or my own properly fitting mouthguard (which has
been approved by the athletic trainer) during all sanctioned supervised practices or competition. I understand I face losing accidental
insurance coverage if I am injured and am not wearing my mouthguard. Should I lose or damage my mouthguard, I understand that it
is my responsibility to obtain a replacement. (_____) I nitial
By signing below, I am certifying that I have read, understood, and am in agreement with all statements above.
________________________________________________________________________________________
Signature of Student-Athlete Date

____________________________________________________________________________________________________________________________________
Signature of Parent/Guardian (if under 18 yrs old) Date

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CONCUSSION DISCLOSURE

Beginning in the Fall 2010 the NCAA is requiring signed disclosure/documentation on head
injury/concussion history, current (if any) symptoms, and responsibility for reporting injuries and illnesses,
including signs, symptoms, and history of concussions to their institutions medical staff.
1. Have you ever been diagnosed with a head injury/concussion? Yes No
If YES explain:__________________________________________________________
2. Have you had more than one concussion? Yes No
If YES how many?: ______________________________________________________
3. Have you ever lost consciousness from a head injury/concussion? Yes No
If YES explain:__________________________________________________________
4. How long did you have symptoms from your last concussion? _____________________
_______________________________________________________________________
5. When was your last concussion? _____________________________________________
6. Do you currently have any symptoms of a concussion, including, but not limited to headache, loss
of memory, dizziness, sensitivity to light, or nausea?
Explain:________________________________________________________________

By signing below I am certifying that I have disclosed all history and current status on head
injuries/concussions to the best of my knowledge. I have made no attempt, either willingly or unknowingly
to misrepresent or withhold any pertinent information.
____________________________________ ________________________
Signature of Student Athlete Date