2014 Medical Form

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE
INTERCOLLEGIATE ATHLETICS THE UNIVERSITY OF TEXAS AT AUSTIN

Post Office Box 7399 Austin, Texas 78713-7399
Men: (512) 471-5513 Women: (512) 471-4916
TO:
Cheerleading, Pom and Mascot Participants
FROM:
Athletic Training/Sports Medicine Staff
SUBJECT:
REQUIRED MEDICAL FORMS AND HEALTHCARE DELIVERY

PROCEDURES
On behalf of our sports medicine staff, were glad to have you with us. Its our job to monitor your
health status. In order to do so effectively, weve attached a few forms that you need to complete.
As we explain the purpose of each form, well also discuss some very important information on
insurance coverage and health care delivery procedures. If you have any questions, please contact
your attending athletic trainer at 512-471-4916.
INSTRUCTIONS
1. UT Athletics Report of Medical History (See Form A): This report includes a questionnaire
designed to solicit information about your personal health history and that of your family. It
is very important for us to know if you or any immediate member of your family (parents,
grandparents, or siblings) has had a history of serious or prolonged illness. We also want to
know if you, specifically, have had a history of previous hospitalizations, surgeries, injuries,
or any other medical conditions that may warrant follow-up care. We request that you be as
thorough as you can when answering the questions. The information collected from the
questionnaire is used by medical providers to ascertain your immediate health status and
conduct a thorough physical examination.
2. Physical Examination (See Form B): In addition to answering questions about your
medical history prior to trying out, you must show proof of a physical examination,
completed in the past 6 months. It is your responsibility to identify a physician who can
conduct your physical examination and complete the form accordingly. Please note that the
medical history and physical exam forms must be reviewed and signed by a physician. If the
physical exam is being performed by a Physicians Assistant (PA) or Nurse Practitioner (NP),
please have all forms co-signed by their supervising physician. We will not accept physical
examination forms without a physicians signature (MD or DO).
3. Express Assumption of Risk/Release and Indemnification Agreement (See Form C): Our
University attorneys require proof that we have informed you in writing that your
participation constitutes an assumption of risk because of the nature of the activity. By
signing this form, you acknowledge that injury is an inherent risk in your activity. This is a
risk that you accept voluntarily, and therefore, will not hold the UT Departments of
Intercollegiate Athletics responsible if you get hurt as a direct result of participation. Note,
there are adult (18 years of age or older) and minor (under 18 years of age requiring your
parents/guardians signature) versions of this form. Choose the appropriate form for your
age. Also, if you are under 18 years of age, your parents/guardians will be required to sign a
form entitled Consent for Treatment of a Minor (See Form D).
4. Authorization to Release Medical Information: If you report for try-outs with a pre-existing
injury or medical condition, you can anticipate that we will request documentation from your
home-based medical providers. Included in this packet is a form that will require your
signature for the release of this information (See Medical Records Release, Providers
Form E).
Required Forms, Medical Procedures page 2
Additionally, if you are ever injured during participation, your care will be provided by the
medical staff of UTs Division of Athletic Training/Sports Medicine. The coaches, program
supervisors, and professional staff; inclusive of athletic trainers, team physicians,
administrative employees, and volunteers, must use and disclose your medical information to
the extent necessary to provide you with quality medical care. In order to do so, we must
follow HIPAA (Health Insurance Portability and Accountability Act) Privacy Practices
required by the law to share your medical information as necessary for treatment, payment,
and health care operations. These privacy practices dictate how your medical information
may be used and disclosed, and how you can get access to this information (See HIPAA
Privacy Notice/Acknowledgment of Receipt Document/Form F).
The Division of Athletic Training/Sports Medicine has policies and procedures in place to
safeguard the privacy of your medical records and protect you from unnecessary disclosure of
your personal health information (PHI). In an athletics setting, there are many parties
including coaches and athletics staff and parent/guardians who can potentially have access to
your PHI, especially in injury situations. Your signature on the appropriate forms permits us
to share this information according to your disclosure preferences (See PHI Forms G1G5).
You have the right to restrict disclosure of your PHI to any of the aforementioned parties by
refusing to sign the appropriate authorization forms. If you choose to do so, you must write,
REFUSED TO AUTHORIZE on the form and include your signature and date for
validity purposes. Also, you have the right to revoke any of your signed authorizations.
Even though you have signed authorizations permitting us to share your personally
identifiable health information, it is imperative to note that we are not obligated to do so. In
accordance with the HIPAA Privacy Standards, we will respect the privacy of your health
information by releasing only the minimum information necessary to protect your health and
safety, and we will strive to do everything necessary to ensure the confidentiality of your
medical records.
5. Insurance Coverage Specifics (Form H): The Intercollegiate Athletics Department cannot
assume financial responsibility if you are injured during the tryout period. Therefore, we are
requesting that you indicate the type of insurance coverage that you possess or that is
maintained for you by your parents/guardians. Your signature, required on this form,
acknowledges that you fully understand the extent of our medical and financial responsibility
if you are injured or become ill during the try out period. You will not be cleared for
participation if you do not have insurance coverage and provide all the information requested.
Insurance Questionnaire (Form H1)/Authorization to Release Insurance Data (Form H2:)
Texas state law requires that you authorize the release, by UT Athletics, of any insurance
information about you. In the event that you are injured, we need to provide this information
to attending physicians and other medical providers who are administering care.
If you do not have insurance at this time, we have provided you with options for coverage.
See Document I Insurance Resource list.

6. Healthcare Delivery Resources/Procedure Since participation in your activity carries with
it the potential for injury, the following specialized medical services, care and supervision are
available.
(a) Resources/Personnel. Primary medical support of our program consists of our team
physicians and certified athletic trainers. Our team physicians arrange for appropriate
emergency, medical, and pharmaceutical services. Additionally, medical resources are
available on campus at the University Health Services located in the Student Services
Building at 100 West Dean Keeton Street.
(b) Athletic Trainer Supervision. In addition to the physician expertise available, a staff
athletic trainer is assigned to monitor your health status. Medical services include
standard first aid care, injury evaluation and treatment and medical referral to team
physicians or specialty consults when indicated. Your attending athletic trainer, in
cooperation with your program director, will schedule daily time blocks for evaluations
and treatments. It is important that you adhere to these time blocks due to the limited
supervisory capacity of our credentialed staff. Furthermore, it is the only way to ensure
consistency in treatments.
(c) Injury Reporting. You are instructed to report any sickness or injury to your attending
athletic trainer as soon as possible. Referrals will be coordinated by your attending
athletic trainer.
(d) Emergency Situations. You may access any member of the sports medicine staff for
immediate care in emergency situations. For all emergency situations including a
possible back or neck injury, possible heat stress, fractures, cessation of breathing or
pulse, and unconsciousness, activate EMS through campus police at 911.
(e) Monitoring of Health Status. Your program director is a key player in helping us
monitor your health status and will keep us informed of any additions or deletions to the
roster. This is the only way that we can ensure that all of you have proper participation
clearance and have been informed as to the extent of our medical and financial
responsibility in the event that you are injured during participation. In turn, we will keep
the program director informed of injuries or illnesses that may require activity status
modifications, if any, and return to play guidelines. Since we are dealing with high
participation numbers, it is very important that you keep lines of communication open
with your program director about how you are feeling.
We also require your program director to be CPR and First Aid certified and to be
familiar with the emergency plan outlined at your training/venue site. These
requirements are necessary to ensure proper handling of injuries in emergency situations.
Return the medical paperwork with the rest of your try-out packet to the address below no
later than seven (7) days prior to your scheduled try-out date. You should retain a copy of
your packet in its entirety for your files.
Spirit Programs Director
Texas Cheer Program
The University of Texas at Austin
2100 San Jacinto
STD 1.246
Austin, TX 78712

Men: (512) 471-5513 Women: (512) 471-4916
Form A
(02-5-2013)
I. Report of Medical History

Name
Phone/Cell
Address
City, State, Zip
UTEID (if one has been assigned)

Year at UT (check): Incoming Freshman
Sex
Freshman
Age
Sophomore
Junior
Sport(s)
Position/Event
Personal Physician
Phone
In case of emergency, contact: Name
Relationship
Phone (H)
(W)
DOB
Senior
(Cell)
Medications: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are
currently taking.
Do you have any allergies?

Medicines
Yes No
Pollens
If YES, please identify specific allergy:

Stinging Insects
Food
Circle questions you dont know the answers. Explain YES answers.
GENERAL QUESTIONS
Yes No
1. Has a doctor ever denied or restricted your participation

in sports for any reason?
2. Do you have any ongoing medical conditions? If so,
please identify below:
Asthma
Anemia
Diabetes Infections
Epilepsy Migraines
Other
3. Have you ever spent the night in the hospital?
4. Have you ever had surgery?
HEART HEALTH QUESTIONS ABOUT YOU

5. Have you ever passed out or nearly passed out DURING
or AFTER exercise?
6. Have you ever had discomfort, pain, tightness, or pressure
in your chest during exercise?
7. Does your heart ever race or skip beats (irregular beats)
during exercise?
8. Has a doctor ever told you that you have any heart
problems? If so, check all that apply:
High blood pressure
A heart murmur
High cholesterol
A heart infection
Kawasaki disease
Other
9. Has a doctor ever ordered a test for your heart?
(For example: ECG/EKG, Echocardiogram)
10. Do you get lightheaded or feel more short of breath than
expected during exercise?
Yes No

EXPLANATION
EXPLANATION
2010 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine,
Form A
(02-5-2013)
Report of Medical History, page 2
HEART HEALTH QUESTIONS ABOUT YOU (cont.)
11. Have you ever had an unexplained seizure?
Yes No
EXPLANATION

12. Do you get more tired or short of breath more quickly

than your friends during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

13. Has any family member or relative died of heart
problems or had an unexpected or unexplained sudden
death before age 50 (including drowning, unexplained
car accident, or sudden infant death syndrome)?
14. Does anyone in your family have hypertrophic
cardiomyopathy, Marfan syndrome, arrhythmogenic right
ventricular cardiomyopathy, long QT syndrome, short QT
syndrome, Brugada syndrome, or catecholaminergic
polymorphic ventricular tachycardia?
15. Does anyone in your family have a heart problem,
pacemaker, or implanted defibrillator?
16. Has anyone in your family had unexplained fainting,
unexplained seizures, or near drowning?
Yes No

BONE AND JOINT QUESTIONS

17. Have you ever had an injury to a bone, muscle, ligament,
or tendon that caused you to miss a practice or game?
Body part:
Yes No

EXPLANATION
EXPLANATION
Injury type:
Missed time:
18. Have you ever had any broken or fractured bones or
dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT
scan, injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an
x-ray for neck instability or atlantoaxial instability?
(Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive
device?
23. Do you have a bone, muscle, or joint injury that bothers
you?
24. Do any of your joints become painful, swollen, feel warm,
or look red?
25. Do you have any history of juvenile arthritis or connective
tissue disease?
MEDICAL QUESTIONS
26. Do you cough, wheeze, or have difficulty breathing during
or after exercise?
27. Have you ever used an inhaler or taken asthma medicine?
Yes No

28. Is there anyone in your family who has asthma?
29. Were you born without or are you missing a kidney, an

eye, a testicle (males), your spleen, or any other organ?
30. Do you have groin pain or painful bulge or hernia in the
groin area?
31. Have you had infectious mononucleosis (mono) within the
last month?
EXPLANATION
Form A
(02-5-2013)
MEDICAL QUESTIONS (continued)
32. Do you have any rashes, pressure sores, or other skin
problems?
33. Have you had a herpes or MRSA (staph) skin infection?
34. Have you ever had a head injury or concussion?
Yes No
EXPLANATION

35. Have you ever had your bell rung?
36. Have you ever had a hit or blow to the head that caused
confusion
prolonged headache
memory problems vision changes

hearing changes
loss of consciousness
dizziness
fogginess
37. Do you have a history of seizure disorder?
38. Do you have headaches with exercise?
39. Have you ever had numbness, tingling, or weakness in

your arms or legs after being hit or failing?
40. Have you ever been diagnosed with a stinger, burner
or pinched nerve?
41. Have you ever been unable to move your arms or legs
after being hit or falling?
42. Have you ever become ill while exercising in the heat?
43. Do you get frequent muscle cramps when exercising?
44. Do you or someone in your family have sickle cell trait or

disease?
45. Have you had any problems with your eyes or vision?
46. Have you had any eye injuries?
47. Do you wear glasses or contact lenses?
48. Do you wear protective eyewear, such as goggles or a face

shield?
49. Do you worry about your weight?
50. Are you trying to or has anyone recommended that you

gain or lose weight?
51. Are you on a special diet or do you avoid certain types of
foods?
52. Have you ever had an eating disorder?
53. During the past month, have you often been bothered by
feeling down, depressed, or hopeless?
54. During the past month, have you often been bothered by
little interest or pleasure in doing things?
55. During the past month, have you been feeling tired or felt
a loss of energy (not associated with sports)?
56. During the past month, have you had difficulty sleeping or
are you sleeping more than is typical for you?
57. Have you ever been diagnosed with an attention deficit
disorder (ADHD)?
58. Do you have any concerns that you would like to discuss
with a doctor?
Form A
(02-5-2013)
FEMALES ONLY
59. Have you ever had a menstrual period?
Yes No

60. If yes, when was your first menstrual period?
Date
61. How old were you when you had your first menstrual
period?
62. When was your most recent menstrual period?
AGE
63. How much time do you usually have from the start of one
period to another?
64. How many periods have you had in the last 12 months?
EXPLANATION
Date
# Periods
65. What was the longest time between periods in the last
year?
66. Have you ever had any of the following problems with
your menstrual cycle that required a visit to a health care
provider?
irregular menses
no menses
painful menses
heavy bleeding
67. When was your last pelvic exam?
Date
68. When was your last breast exam?
Date
69. Have you ever had an abnormal pelvic exam or pap

smear?
Yes No

70. Are you currently taking oral contraceptive or birth control

pills?
Yes No

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Date
Signature of Athlete
Signature of Parent or Guardian (if student is under 18 years of age)
Date
```````````````````````````````````````````````````````````````````````````````````````````````
Reviewed by James Bray, MD
Andrea Pana, MD
Tim Vachris, MD
Athletic Trainer
Other
Date
Are there any changes since the questionnaire was completed? Yes No
Form B
(2-5-13)
IX. Preparticipation Physical Examination: UT Division of Athletic Training/Sports Medicine

To be completed by Attending Physician only:
Name
Sport
UTEID
Date of Birth
PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues:

Do you feel stressed out or under a lot of pressure?
Do you feel safe at your home or residence?
During the past 30 days, did you use chewing tobacco, snuff, or dip?
Have you ever taken any supplements to help you gain
or lose weight or improve your performance?
Do you practice safe sex?
Do you ever feel sad, hopeless, depressed, or anxious?

Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
Do you drink alcohol or use any other drugs?
Have you ever taken anabolic steroids or used any other performance supplement?
Do you wear a seat belt, use a helmet, and use condoms?
Do you have a history of any sexually transmitted infections?
2. Consider reviewing questions on cardiovascular symptoms (questions 5-14).
EXAMINATION
Height
BP
Weight
(
Male
)
Pulse
Female
Vision R20
MEDICAL
Appearance
Marfan stigma (kyphoscoliosis, high-arched palate, pectus excavatum,
arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes / ears / nose / throat
Pupils equal
Hearing
Lymph Nodes
Hearta
Murmurs (auscultation standing, supine, +/- Valsalva)
Location of point of maximal impulse (PMI)
Pulses
Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)b
Skin
HSV, lesions suggestive of MRSA, tinea coporis
Neurologicc
MUSCULOSKELETAL
Neck
Back
Shoulder / Arm
Wrist / Hand / Fingers
Hip / Thigh
Knee
Leg / Ankle
Foot / Toes
Functional
Duck-walk, single leg hop
a
b
c
Corrected
L 20
NORMAL
ABNORMAL FINDINGS
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
Consider GU exam if in private setting. Having third party present is recommended.
Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for
Not Cleared
Pending further evaluation
For any sport
For certain sports
Reason
Recommendations
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined
above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may
rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).
Physicians Name James Bray, MD
Andrea Pana, MD
Tim Vachris, MD
Other
Address
Physicians Signature
Phone
, MD or DO
Date
Sports Medicine, Policy and Procedural Manual

Form C-Adult

Men: (512) 471-5513 Women: (512) 471-4916
ASSUMPTION OF RISK/RELEASE AND INDEMNIFICATION AGREEMENT
PARTICIPANTS
NAME:
SPORT/ACTIVITY:
The University of Texas at Austins Departments of Intercollegiate Athletics is concerned about the health and
well-being of its prospective student-athletes/participants. However, the health status and physiological
capabilities of individuals who are not recruited student-athletes/participants at the time of team/activity tryouts
are not known to the Universitys athletics personnel or sports medicine providers. Therefore, it is necessary for
any individual desiring to tryout for an intercollegiate athletics team/activity to certify that he/she is in adequate
physical condition to undergo such tryouts, and to release the state of Texas, Intercollegiate Athletics, the
athletic team and all of their respective members, officers, employees, and agents (hereinafter referred to as The
University of Texas) from any liability for not providing proof of medical examinations, athletic trainers
examinations, or physical fitness assessments prior to the tryout.
I, the above named participant, am eighteen years of age or older am fully competent to sign this agreement.
I realize that my participation in the aforementioned sport/activity carries with it risk of injury/illness, even
when all rules are followed and conditions are optimal. There are various safety problems that can increase
injury risk potential. Some safety problems are regularly identified and addressed (i.e., heat illness and the
administration of liquids frequently during practices; collisions and the use of high quality, durable, and safe
protective equipment). Other safety problems may be less clearly identified (i.e., mechanisms of head and neck
injuries or ankle and knee injuries) and, therefore, prevention and protection are difficult. Risk can be increased
due to the participants lack of compliance with specified instructions (i.e., using improper footwear, knowingly
using dangerous or faulty equipment, training when environmental conditions are dangerous (high heat/high
humidity, lighting), and engaging in high intensity or high volume training without adequate fitness or
conditioning. Even in the best facilities, with adequate supervision, use of all protective equipment, and
compliance with all of the rules, there remains an inherent risk of injury/illness as a result of my participation,
and this risk is increased even more so with contact sports/activities.
I acknowledge that my voluntary participation may expose me to hazards or risks that may result in my personal
injury/illness or death. I acknowledge that I am aware of the risks of injury/illness and knowledgeable
concerning rules, equipment and safety practices being employed by UT athletics personnel to minimize my risk
of sustaining an injury/illness as a result of participation. I agree to use all required protective equipment and
follow all rules and instructions from University officials regarding my safety. Also, I have no known physical
infirmities which could be worsened or aggravated by my participation and I declare myself physically fit and in
good medical condition to engage in all athletics activities.
In consideration for The University granting me permission to engage in said tryout, and therefore foregoing its
right to prevent me from participating in said tryout, I hereby release The University of Texas at Austin, its
Board of Regents, Officers, Employees, and Representatives from any and all liability, claims, costs or expenses
resulting from any and all injuries (including death) or infirmities that may result in the course of my
participation/tryout. I understand that The University of Texas at Austin and all its insurers will not be
responsible for any of my medical expenses, pain and suffering, present or future lost wages or diminished
earning capacity, or any other damages that may arise from any injury or infirmity that may result in the course
of my participation/tryout. I further agree to indemnify and hold harmless the Institution and its governing
board, officers, employees, and representatives from liability for the injury or death of any person(s) and
Adult
Apvd. by UT Austin Legal, JG, 06/01/2010
Form C-Adult
. . . Authorization of Risk/Release and Indemnification Agreement, page 2

damage to property that may result from my negligent or intentional act or omission while participating
I have carefully read this agreement and I understand that it is a legally binding document that affects my legal
rights and remedies. I acknowledge that I am signing this waiver voluntarily and with complete understanding of
the terms and conditions contained herein.
Signature of Participant
Date
Witness (over 21 years of age)
Date
Adult
Form C-Minor

Men: (512) 471-5513 Women: (512) 471-4916
ASSUMPTION OF RISK/RELEASE AND INDEMNIFICATION AGREEMENT
(Applicable only if participant is under 18 years of age)
PARTICIPANTS
NAME:
SPORT/ACTIVITY:
The University of Texas at Austins Departments of Intercollegiate Athletics is concerned about the health and
well-being of its prospective student-athletes/participants. However, the health status and physiological
capabilities of individuals who are not recruited student-athletes/participants at the time of team/activity tryouts
are not known to the Universitys athletics personnel or sports medicine providers. Therefore, it is necessary for
any individual desiring to tryout for an intercollegiate athletics team/activity to certify that he/she is in adequate
physical condition to undergo such tryouts, and to release the state of Texas, Intercollegiate Athletics, the athletic
team and all of their respective members, officers, employees, and agents (hereinafter referred to as The
University of Texas) from any liability for not providing proof of medical examinations, athletic trainers
examinations, or physical fitness assessments prior to the tryout.
I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and I am fully
competent to sign this agreement.
I realize that my sons/daughters participation in the aforementioned sport/activity carries with it risk of
injury/illness, even when all rules are followed and conditions are optimal. There are various safety problems that
can increase injury risk potential. Some safety problems are regularly identified and addressed (i.e., heat illness
and the administration of liquids frequently during practices; collisions and the use of high quality, durable, and
safe protective equipment). Other safety problems may be less clearly identified (i.e., mechanisms of head and
neck injuries or ankle and knee injuries) and, therefore, prevention and protection are difficult. Risk can be
increased due to the participants lack of compliance with specified instructions (i.e., using improper footwear,
knowingly using dangerous or faulty equipment, training when environmental conditions are dangerous (high
heat/high humidity, lighting), and engaging in high intensity or high volume training without adequate fitness or
conditioning. Even in the best facilities, with adequate supervision, use of all protective equipment, and
compliance with all of the rules, there remains an inherent risk of injury/illness as a result of my participation, and
this risk is increased even more so with contact sports/activities.
I acknowledge that my sons/daughters voluntary participation may expose him/her to hazards or risks that may
result in his/her personal injury/illness or death. I acknowledge that I am aware of the risks of injury/illness and
knowledgeable concerning rules, equipment and safety practices being employed by UT athletics personnel to
minimize my sons/daughters risk of sustaining an injury/illness as a result of participation. My son/daughter
agrees to use all required protective equipment and follow all rules and instructions from University officials
regarding safety. Also, my son/daughter has no known physical infirmities which could be worsened or
aggravated by participation and I declare him/her physically fit and in good medical condition to engage in all
athletics activities.
In consideration for The University granting my son/daughter permission to engage in said tryout, and therefore
foregoing its right to prevent him/her from participating in said tryout, I hereby release The University of Texas at
Austin, its Board of Regents, Officers, Employees, and Representatives from any and all liability, claims, costs or
expenses resulting from any and all injuries (including death) or infirmities that may result in the course of his/her
Minor
Form C-Minor
. . . Authorization of Risk/Release and Indemnification Agreement, page 2

participation/tryout. I understand that The University of Texas at Austin and all its insurers will not be responsible
for any of my sons/daughters medical expenses, pain and suffering, present or future lost wages or diminished
earning capacity, or any other damages that may arise from any injury or infirmity that may result in the course of
my sons/daughters participation/tryout. I further agree to indemnify and hold harmless the Institution and its
governing board, officers, employees, and representatives from liability for the injury or death of any person(s)
and damage to property that may result from my sons/daughters negligent or intentional act or omission while
participating.
I have carefully read this agreement and I understand that it is a legally binding document that affects my legal
rights and remedies. I acknowledge that I am signing this waiver voluntarily and with complete understanding of
the terms and conditions contained herein.
Signature of Parent/Guardian
Date Signed
Signature of Witness (over 21 years of age)
Date Signed
Minor
Address (if different than Participant)
Form D

Men: (512) 471-5513 Women: (512) 471-4916
CONSENT FOR TREATMENT OF A MINOR

(Applicable only if participant is under 18 years of age)
STUDENT-ATHLETE:
SPORT:
I, the undersigned, as the parent or legal guardian of (a minor) hereby authorize such diagnostic, medical and/or
surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the
treatment of any illness or injury of the minor. The attending physician(s), athletic trainers, appropriate staff,
and The University of Texas at Austin and its officers, regents, and employees shall not be responsible in any
way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from
any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment,
or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the
best of their ability.
Signature of Parent/Legal Guardian
Minor
Date Signed
Do not fill out any information on the following form,

Medical Records Release, with the exception of your
signature and date on the bottom of the page. If you are
under 18 years of age, your parents/guardians will have
to sign for you.

Post Office Box 7399 Austin, Texas 78713-7399 Men: 512/471-5513 Women: 512/471-4916
Form E
(2-05-13)
MEDICAL RECORDS RELEASE: PROVIDERS

Athletes Name:
DOB:
UTEID:
I authorize information released from my home based physician,

Dr. James Bray, Head Team Physician (FAX: 512/232-5054)
Division Athletic Training/Sports Medicine
Intercollegiate Athletics
Post Office Box 7399
Austin, Texas 78713-7399
to:
Purpose of Release (please check box):
Changing Primary Care Physician/Clinic

Referral/Consultation
Insurance Legal
Continuation of care
Self/Other
Type of Information to be Released:

General Medical Records (excluding protected records): Copies of medical records will include lab and x-rays
unless otherwise requested.
Specific Information Only:
History and Physical
Specific Date:
Medications/Therapy
Lab, Pathology, EKG
Specify:
X-ray/Imaging
Type:
Date Taken:
Report:
Operative Report
Type of Surgery:
Accident or Injury
Dates from:
to:
Immunizations
Other
Protected or sensitive information: I understand that certain information cannot be released without specific
authorization as required by State/Federal law. BY INITIALING I authorize the release of the following protected
or sensitive information.
Drug Abuse Diagnosis/Treatment
Initial
Sexually Transmitted Diseases

Initial
Alcoholism Diagnosis/Treatment
Initial
AIDS/HIV Test Results Including Related High Risk Behavior

Initial
Mental Health/Treatment
Initial
Genetic Testing
Initial
The reason for this disclosure is to advise The University of Texas Athletic Training/Sports Medicine Personnel of the nature, diagnosis,
prognosis, or medical treatment concerning my medical condition and any injuries or illnesses so that they may provide appropriate
medical care to me while I am a student-athlete. I understand that if the person or entity that receives the information is not a health care
provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer
protected by those regulations.
I understand that The University of Texas at Austin will not receive compensation for its use/disclosure of the information. I understand
that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment. I may inspect or
copy any information used/disclosed under this authorization.
I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be
protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS test or result
information, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral information. I
understand that the person or entity I am authorizing to use and/or disclose the information may receive compensation for doing so. I
understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain health care services
are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.
My refusal to sign this authorization will not adversely affect my enrollment in a healthcare plan or eligibility to enroll in the health plan
unless the authorized information is necessary to determine if I am eligible in the health plan. I understand that I may revoke this
authorization in writing at any time, except to the extent that action has been taken in reliance upon this authorization. If I revoke my
authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization.
Unless revoked earlier, this authorization will expire 90 days from the date of signing or on (insert applicable date or event).
Signature of Patient or Legally Responsible Person
Relationship to Patient
Date
Document F
THE UNIVERSITY OF TEXAS AT AUSTIN

INTERCOLLEGIATE ATHLETICS
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
HIPAA PRIVACY RULES REQUIRE THAT WE FURNISH YOU WITH THIS NOTICE.
I. Purpose: The Division of Athletic Training/Sports Medicine of Intercollegiate Athletics at The
University of Texas at Austin and its professional staff, employees, and volunteers follow the privacy
practices described in this Notice. The Sports Medicine Division maintains your medical information in
records that will be handled in a confidential manner, as required by law. However, the Sports Medicine
Division must use and disclose your medical information to the extent necessary to provide you with
quality health care. To do this, the Sports Medicine Division must share your medical information as
necessary for treatment, payment, and health care operations.
II. What Are Treatment, Payment, and Health Care Operations? Treatment includes sharing
information among health care providers involved in your care. For example, your treatment provider may
share information about your condition with other treatment providers in the Sports Medicine Division in
order to make a diagnosis. The Sports Medicine Division may use your medical information as required by
your insurer to obtain payment for your treatment. We also may use and disclose your medical information
to improve the quality of care, e.g., for review and training purposes.
III. What Are Other Ways the Sports Medicine Division May Use Your Medical Information? Your
medical information may be used, unless you ask for restrictions on a specific use of disclosure, for
the following purposes:
Appointment reminders.
To inform you of treatment alternatives or benefits or services related to your health. (You will
have an opportunity to refuse to receive this information.)
To carry out health care treatment, payment, and operations functions through business associates,
e.g., to install a new computer system.
Alcohol and drug abuse information has special privacy protections. The Sports Medicine
Division will not disclose any information identifying an individual as being a student-athlete or
provide any medical information relating to a student-athletes substance abuse treatment unless:
(i) the student-athlete consents in writing; (ii) a court order requires disclosure of the information;
(iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel
use this information for the purpose of conducting scientific research, management audits,
financial audits, or program evaluation; or (v) it is necessary to report a crime or a threat to
commit a crime, or to report abuse or neglect as required by law.
Workers Compensation. (Your medical information regarding benefits for work-related

illnesses may be released as appropriate.)
Health oversight activities, e.g., audits, inspections, investigations, and licensure.
Sports Medicine, Policy and Procedure Manual

Document F
. . . Notice of Privacy Practices, page 2

Certain research projects.
To prevent a serious threat to health or safety.
Law enforcement (e.g., in response to a court order or other legal process; to identify or locate an
individual being sought by authorities; about the victim of a crime under restricted circumstances;
about a death that may be the result of criminal conduct; circumstances relating to reporting
information about a crime).
Disaster relief agency if injured in a disaster.
National security and intelligence activities.
Protection of the President or other authorized persons for foreign heads of state, or to conduct
special investigations.
Lawsuits and disputes. (We will attempt to provide you advance notice of a subpoena before
disclosing the information.)
As required by law.
IV. Your Authorization Is Required for Other Disclosures. Except as described above, we will not
use or disclose your medical information unless you authorize the Sports Medicine Division in writing to
disclose your information. You may revoke your permission, which will be effective only after the date of
your written revocation. Your medical records may also contain psychotherapy notes from individual,
joint, group or family sessions you may have participated in. You will need to sign a separate authorization
form for the use and disclosure of this information. You may revoke your permission to use and disclose
your psychotherapy records by sending a written revocation to the Sports Medicine Division.
IV. You Have Rights Regarding Your Medical Information.
You have the following rights regarding your medical information, provided that you make a written
request to invoke the right.
Right to request restrictions. You may request limitations on your medical information that we use or
disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you
have had a particular treatment), but we are not required to agree to your request. If we agree, we will
comply with your request unless the information is needed to provide you with emergency services.
Right to confidential communications. You may request communication in a certain way or at a certain
location, but you must specify how or where you wish be contacted.
Right to inspect and request a copy. You have the right to inspect and request a copy of your medical
information regarding decisions about your care. We charge a fee for copying, mailing, and supplies. Under
limited circumstances, your request may be denied; in that instance you may request review of the denial
by another licensed health care professional chosen by the Sports Medicine Division. The Sports Medicine
Division will comply with the outcome of the review.
Right to request amendment. If you believe that the medical information we have about you is incorrect
or incomplete, you may request an amendment, which requires certain specific information. The Sports
Medicine Division is not required to accept the amendment.

Document F
. . . Notice of Privacy Practices, page 3

Right to accounting disclosures. You may request a list of the disclosures of your medical information
that have been made to persons or entities other than for health care treatment, payment, or operations in
the past six (6) years, but not prior to April 14, 2003. After the first request, there will be a charge.
Right to a copy of this Notice. You may request a copy of this Notice at any time, even if you have been
provided with an electronic copy.
VI. Requirements Regarding This Notice. The Sports Medicine Division is required by law to provide
you with this Notice. We will be governed by this Notice for as long as it is in effect. The Sports Medicine
Division may change this Notice and these changes will be effective for medical information we have about
you as well as any information we receive in the future.
Each time you register with the Sports Medicine Division for health care services, you may receive a copy
of the Notice in effect at the time.
VII. Complaints. If you believe your privacy rights have been violated or:
You have a complaint.
You have any questions about this Notice.
You wish to request restrictions on uses and disclosures for health care treatment, payment, or
operations.
You wish to obtain forms to exercise your individual rights described in paragraph V.
Call xxxx xxxxx in the Sports Medicine Division of Intercollegiate Athletics at (xxx) xxx-xxxx.

Form F
THE UNIVERSITY OF TEXAS AT AUSTIN

INTERCOLLEGIATE ATHLETICS
PARTICIPANT ACKNOWLEDGEMENT
RECEIPT OF THE HIPAA PRIVACY PRACTICE NOTICE
I ________________________________________ acknowledge that I have received a copy of

(print name)
The Notice of Privacy Practices of the Sports Medicine Division of Intercollegiate Athletics at
The University of Texas at Austin.
Date:
Signed:
Signed:
(If student is under 18 years of age, parents/guardians signature)

PHI-Form G1

Men: (512) 471-5513 Women: (512) 471-4916
PHI AUTHORIZATION RELEASE OF MEDICAL INFORMATION TO PARENTS

OR GUARDIANS
PARTICIPANT:
ACTIVITY:
This authorizes the athletic trainers, team physicians and athletics staff including coaches representing The
University of Texas at Austin to release information concerning my medical status, medical condition, injuries,
prognosis, diagnosis, and related personally identifiable health information to my parents/guardian. This
information includes injuries or illnesses relevant to past, present or future participation at The University of
Texas at Austin.
The reason for this disclosure is to advise my parent/guardian of the nature, diagnosis, prognosis or treatment
concerning my medical condition and any injuries or illnesses so that they may assist me in making healthcare
decisions while I am a participant. I understand that the entities that receive the information are not health care
providers or health plans covered by federal privacy regulations, and that the information described above may
be redisclosed publicly and that the information will no longer be protected by those regulations.
I understand that The University of Texas at Austin will not receive compensation for its use/disclosure of the
information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect
my ability to obtain treatment. I may inspect or copy any information used/disclosed under this authorization.
I understand that I may revoke this authorization in writing at any time by notifying in writing the Co-Director
of the Division of Athletic Training/Sports Medicine, but if I do, it will not have any effect on actions The
University took in reliance on this authorization prior to receiving the revocation. This authorization expires six
years from the date it is signed.
Date

(If participant is under 18 years of age)
Date
Apvd. by UT Austin Legal, JG, 2004, 05/25/2010
PHI-Form G2

Men: (512) 471-5513 Women: (512) 471-4916
PHI AUTHORIZATION RELEASE OF MEDICAL INFORMATION TO COACHES

AND ATHLETICS STAFF
PARTICIPANT:
SPORT/ACTIVITY:
This authorizes the athletic trainers, team physicians, and sports medicine staff representing The University of
Texas at Austin to release information concerning my medical status, medical condition, injuries, prognosis,
diagnosis, and related personally identifiable health information to the coaches, assistant coaches and other
athletics staff. This information includes injuries or illnesses relative to past, present or future participation in
athletics at The University of Texas at Austin.
The reason for this disclosure is to advise the coaches and athletics staff of the nature, diagnosis, prognosis or
treatment concerning my medical condition and any injuries or illnesses so that they may make decisions
regarding my athletic ability and suitability to participate at the highest level. I understand that the entities that
receive the information are not health care providers or health plans covered by federal privacy regulations, and
that the information described above may be redisclosed publicly and that the information will no longer be
protected by those regulations.
my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this
authorization.
Date

Date
Apvd.by UT Austin Legal, JG, 2004, 05/25/2010
PHI-Form G3

Men: (512) 471-5513 Women: (512) 471-4916
PHI AUTHORIZATION RELEASE OF MEDICAL INFORMATION TO TEAMMATES
PARTICIPANT:
ACTIVITY:
prognosis, diagnosis, and related personally identifiable health information to my teammates. This information
includes injuries or illnesses relevant to past, present or future participation in athletics at The University of
Texas at Austin.
The reason for this disclosure is to advise my teammates of the nature, diagnosis, prognosis or treatment
concerning my medical condition and any injuries or illnesses so they may be aware of physical limitations that
may affect my participation status. I understand that the entities that receive the information are not health care
providers or health plans covered by federal privacy regulations, and that the information described above may
be redisclosed publicly and that the information will no longer be protected by those regulations.
Signature of Participoant
Date

Date
Apvd. By UT Austin Legal, JG, 2004, 05/25/2010
PHI-Form G4

Men: (512) 471-5513 Women: (512) 471-4916
PHI AUTHORIZATION RELEASE OF MEDICAL INFORMATION TO STUDENT

ATHLETIC TRAINERS AND OTHER STUDENT MEMBERS OF THE SPORTS
MEDICINE STAFF
PARTICIPANT:
SPORT/ACTIVITY:
This authorizes the athletic trainers, team physicians, and sports medicine staff representing The University of
Texas at Austin to release information concerning my medical status, medical condition, injuries, prognosis,
diagnosis, and related personally identifiable health information to the student athletic trainers and other
students who are participating in the provision of healthcare. This information includes injuries or illnesses
relative to past, present or future participation in athletics related activities at The University of Texas at Austin.
The reason for this disclosure is to allow such students to assist and participate in caring for me under
credentialed supervision while I am an active participant. I understand that the entities that receive the
information are not health care providers or health plans covered by federal privacy regulations, and that the
information described above may be redisclosed publicly and that the information will no longer be protected
by those regulations.
my ability to obtain medical treatment. I may inspect or copy any information used/disclosed under this
authorization.
Date

Date
PHI-Form G5

Men: (512) 471-5513 Women: (512) 471-4916
PHI AUTHORIZATION RELEASE OF MEDICAL INFORMATION TO THE MEDIA
PARTICIPANT:
SPORT/ACTIVITY:
prognosis, diagnosis, and related personally identifiable health information to the media including specifically
UTs Sports Information Department and to the various media outlets. This information includes injuries or
illnesses relevant to past, present or future participation in athletics at The University of Texas at Austin.
The reason for this disclosure is to advise designated representatives from print, radio, television and other
media of the nature, diagnosis, prognosis or treatment concerning my medical conditions and any injuries or
illnesses that are sustained so that they may be reported on accurately while I am a participant. I understand
that the entities that receive the information are not health care providers or health plans covered by federal
privacy regulations, and that the information described above may be redisclosed publicly and that the
information will no longer be protected by those regulations.
Date

Date
Form H
Men: (512) 471-5513 Women: (512) 471-4916
INSURANCE AUTHORIZATION FOR UT STUDENTS TRYING OUT

FOR SPIRIT SQUADS
UT Austin students wishing to try out for spirit squads under the auspices of the Department of Intercollegiate
Athletics at The University of Texas at Austin can do so only if they (1) show proof of insurance coverage; (2)
complete release of liability and authorization forms; (3) complete a medical history questionnaire; and, (4)
provide documentation of physician clearance within the past 6 months.
Name of Participant
(please print)
I, the above-named participant, am eighteen years of age or older and have requested to try out for the sirit
squads. I understand that there is no insurance coverage provided by the Departments of Intercollegiate
Athletics at The University of Texas at Austin for injuries/illnesses of any nature incurred in team practices or
transportation to such practices during the try-out period. Therefore, in order for me to be permitted to try out, I
must show proof of insurance coverage.
I am covered by my family insurance policy or insurance purchased by myself . I have completed the
insurance questionnaire enclosed in this packet indicating the specifics of my coverage. I understand the
following: (1) it is my responsibility to maintain insurance coverage during the length of the try out and, if I am
added to the team, during the length of my participation; (2) I am to apprise appropriate UT sports medicine
personnel (Lisa Sova, Insurance Coordinator, 512-471-7569) of any changes in my coverage. If I fail to do so, I
will be responsible for medical expenses from any injuries/illnesses incurred from the date that the insurance
lapses; and, (3) I may be subject to suspension from participation until I obtain insurance from another source.
I also understand that my insurance plan must provide coverage for sports related medical conditions. It is my
responsibility to determine if my insurance plan meets this requirement. If it does not, I acknowledge that I
have been given a list of insurance plans from UT sports medicine personnel that do meet the criteria. I further
understand that the list only serves as a resource for purchasing an individual medical policy and that the
Department of Intercollegiate Athletics does not have any affiliation or arrangement with any insurance
company or its independent agents.
I am signing this agreement voluntarily and with complete understanding of the terms and conditions contained
herein.
Participants Signature
Date of Signature
Parents Signature (if participant is under 18 years of age)
Date of Signature
Form H1
(2-5-13)

Phone: (512) 471-7569/1545 Fax: (512) 232-5054
INSURANCE QUESTIONNAIRE
This form must be filled out, signed, and returned before you will be allowed to participate on a varsity
intercollegiate athletics team at The University of Texas at Austin.
SECTION I: MEDICAL SERVICE INSURANCE AGREEMENT I acknowledge receiving the UT-Austin Athletics
insurance procedural letter. I understand the extent of The Universitys responsibility if I am injured or ill as a
result of participating in intercollegiate sports. I also understand there is an assumed risk involved in participating in
intercollegiate sports/activities.
Print Name
Birth Date:
Student-Athletes Signature
UTEID (if one has been assigned):
Marital Status: Single Married
Date
Sport:
Your Email:
CHECK BOX IF YOU HAVE NO INSURANCE
Cell Phone #:
SECTION II: POLICYHOLDER INFORMATION (Please Print)
Policyholders Name:
Policyholders DOB:
Policyholder Gender: Male Female

Student-Athletes Relationship to Policyholder: Child Spouse Self Other:
Policyholders Address:
Home Phone #:
Cell Phone #:
Home Email:
Is Ins. Thru Employer? YES NO
Employed
Retired
Unemployed
Employer:
Employer Phone #:
Fax #:
Employers Address:
Work Email:
SECTION III: HEALTH INSURANCE INFORMATION
(Please Print)
Insurance Company:
Policyholders ID #:
Group Plan Policy Account #:
Payer ID#
Plan Type: HMO PPO POS Medicaid Other:

Benefits Phone #:
PreCertification Ph #:
Claims Mailing Address:

Primary Care Physician (PCP) Name:
PCP Phone #:
Pharmacy Insurance Co.:
NO Pharmacy Insurance
Policyholders ID #:
Benefits Phone #:
RXBIN#
RXGrp#

Dental Insurance Co.:
NO Dental Insurance
Policyholders ID #:
Group#
Benefits Phone #:
Plan
Payer ID#

- Front and Back Copies of Medical, Prescription and Dental Insurance Card MUST BE Attached to This Form -
Form H2

Men: (512) 471-5513 Women: (512) 471-4916
AUTHORIZATION TO RELEASE INSURANCE DATA
I hereby authorize the Division of Athletic Training/Sports Medicine to release personal insurance data about
me for purposes of certification of injury, illness, physical examination, and other legitimate reasons related to
health coverage and participation clearance.
I authorize the Division of Athletic Training/Sports Medicine and The University of Texas at Austin (The
University) to file on my insurance for any illness or injuries related to participation.
I authorize my insurance company to pay direct to the medical provider or to The University, whichever The
University directs.
I further authorize the release of my sons/daughters medical or patient accounting records to my insurance
company and/or to The University.
Name of Participant (please print)
UTEID (if one has been assigned)
Participants Signature
Date
Date of Birth
Parent/Guardians Signature
Date
Date of Birth
In accordance with the Family Educational Rights and Privacy Act of 1974, this information is released on the
condition that you will not permit any other party access to the information without the written consent of the
individual whose record it is.

Form I

Men: (512) 471-1545 Women: (512) 471-7569
INSURANCE RESOURCE LIST
The University of Texas at Austin Intercollegiate Athletics Department requires that you have medical
insurance coverage prior to participation with your respective team. It is your responsibility to ensure
that the appropriate coverage is obtained and maintained during the length of your participation. The
University of Texas at Austin offers a student medical insurance plan through United Healthcare that
can be acquired through the University Health Services. However, this plan is NOT a viable option as it
excludes medical treatment related to any injuries sustained while participating in intercollegiate
athletics. The insurance plan that you acquire must meet one important requirement that it covers you
for all injuries sustained during participation in your activity.
The list below of insurance plans meets this requirement and serves only as a resource for purchasing an
individual medical policy. The University of Texas at Austin Athletics Departments does not have any
affiliation or arrangement with any insurance company or its independent agents.
State Farm Insurance contracts with Assurant Health for individual medical policies. For information regarding
the policies offered contact State Farm at 877/734-2265 or at the web site: http://www.statefarm.com.
Farmers Insurance Group contracts with Unicare for individual medical policies. For information regarding the
policies offered contact Farmers at 208/239-8400 or 800/327-6377 or at the web site:
http://www.farmers.com/FarmComm/index.html.
Golden Rule Insurance Company provides individual medical policies. For information regarding the policies
offered contact Golden Rule at 800/444-8990 or at the web site: http://www.goldenrule.com/.
Assurant Health offers individual medical policies. For information regarding the policies offered contact
Assurant Health at 800/800-1212 or at the web site: http://www.assuranthealth.com/corp/ah/.
Unicare offers individual medical policies. For information regarding the policies offered contact Unicare at
800/683-2273, at the web site: http://www.unicare.com, or email Direct.Sales@WellPoint.com.
Celtic Insurance Company offers individual medical policies. For information regarding the policies offered
contact Celtic at 312/332-5401 or 800/477-7870, or at the web site: http://www.celtic-net.com/.


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DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE

INTERCOLLEGIATE ATHLETICS THE UNIVERSITY OF TEXAS AT AUSTIN

Cheerleading, Pom and Mascot Participants

Athletic Training/Sports Medicine Staff

REQUIRED MEDICAL FORMS AND HEALTHCARE DELIVERY

Required Forms, Medical Procedures page 3

Required Forms, Medical Procedures page 4

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE

I. Report of Medical History

City, State, Zip

UTEID (if one has been assigned)

In case of emergency, contact: Name

Do you have any allergies?

If YES, please identify specific allergy:

1. Has a doctor ever denied or restricted your participation

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU

12. Do you get more tired or short of breath more quickly

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

BONE AND JOINT QUESTIONS

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an

Report of Medical History, page 3

35. Have you ever had your bell rung?

memory problems vision changes

38. Do you have headaches with exercise?

39. Have you ever had numbness, tingling, or weakness in

43. Do you get frequent muscle cramps when exercising?

44. Do you or someone in your family have sickle cell trait or

46. Have you had any eye injuries?

47. Do you wear glasses or contact lenses?

48. Do you wear protective eyewear, such as goggles or a face

50. Are you trying to or has anyone recommended that you

60. If yes, when was your first menstrual period?

68. When was your last breast exam?

69. Have you ever had an abnormal pelvic exam or pap

70. Are you currently taking oral contraceptive or birth control

Signature of Parent or Guardian (if student is under 18 years of age)

IX. Preparticipation Physical Examination: UT Division of Athletic Training/Sports Medicine

1. Consider additional questions on more sensitive issues:

Do you ever feel sad, hopeless, depressed, or anxious?

2. Consider reviewing questions on cardiovascular symptoms (questions 5-14).

Cleared for all sports without restriction

For any sport

For certain sports

Physicians Name James Bray, MD

Sports Medicine, Policy and Procedural Manual

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE

. . . Authorization of Risk/Release and Indemnification Agreement, page 2

Witness (over 21 years of age)

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE

. . . Authorization of Risk/Release and Indemnification Agreement, page 2

Signature of Witness (over 21 years of age)

Address (if different than Participant)

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE

CONSENT FOR TREATMENT OF A MINOR

Signature of Parent/Legal Guardian

Do not fill out any information on the following form,

DIVISION OF ATHLETIC TRAINING/SPORTS MEDICINE

MEDICAL RECORDS RELEASE: PROVIDERS

I authorize information released from my home based physician,

Changing Primary Care Physician/Clinic