HomeMy WebLinkAboutSpecial Olympics Iowa release medical packet
Athlete Registration Form for US Programs – updated July 2017 (SOI)
ATHLETE INFORMATION FORM
Please submit to physicals@soiowa.org
ATHLETE INFORMATION
First Name: Middle Name:
Last Name: Preferred Name:
Date Birth (mm/dd/yyyy): ☐ Female ☐ Male
Race/Ethnicity (Optional):
☐ American Indian/Alaskan Native
☐ Black or African American
☐ White
☐ Asian ☐ Two or More Races
☐ Native Hawaiian or Other Pacific Islander
☐ Hispanic or Latino (specific origin group:_________________________)
Language(s) Spoken in Athlete’s Home (Optional): Check all that apply
☐ English ☐ Spanish ☐ Other (please list):
Street Address:
City: State: Postal Code:
Phone: E-mail:
Sports/Activities:
Athlete Employer, if any (Optional):
Does the athlete have the capacity to consent to medical treatment on his or her own behalf? ☐Yes ☐ No
PARENT / GUARDIAN INFORMATION (required if minor or otherwise has a legal guardian)
Name:
Relationship:
☐ Same Contact Info as Athlete
Street Address:
City: State: Postal Code:
Phone: E-mail:
EMERGENCY CONTACT INFORMATION
☐ Same as Parent/Guardian
Name:
Phone: Relationship:
PHYSICIAN / INSURANCE INFORMATION
Physician Name:
Physician Phone:
Insurance Company: Insurance Policy Number:
Insurance Group Number:
Special Olympics Iowa Delegation/Team: ___________________________________
Are you a new athlete to Special Olympics or Re-Registering? ☐ New Athlete ☐ Re-Registering
Has the athlete’s Health History changed in the last three years?
If Yes please submit an updated Health History along with the Exam. ☐ Yes ☐ No
Updated 4 August 2017
PARTICIPANT RELEASE FORM
Please submit to physicals@soiowa.org
Name: __________________________________________ Delegation: ____________________________
Date of Birth: _________ / _________ / _________ Gender: Female Male
I agree to the following:
1. Ability to Participate. I am physically able to take part in Special Olympics activities.
2. Likeness Release. I give permission to Special Olympics to use my photo, video, name, voice, and words to promote Special Olympics
and raise funds for Special Olympics. For this form, “Special Olympics” means all Special Olympics organizations.
3. Risk of Concussion and Other Injury. I know there is a risk of injury. I understand the risk of continuing to play sports with a
concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury. I also may have to wait
7 days or more and get permission from a doctor before I start playing sports again.
4. Emergency Care. If I am unable, or my guardian is unavailable, to consent or make medical decisions in an emergency, I authorize
Special Olympics to seek medical care on my behalf, unless I mark one of these boxes:
I have a religious or other objection to receiving medical treatment.
I do not consent to blood transfusions.
(If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.)
5. Overnight Stay. For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask.
6. Health Programs. If I take part in a health program, I consent to health activities, screenings, and treatment. This should not replace
regular health care. I can say no to treatment or anything else at any time.
7. Personal Information. I understand that Special Olympics is collecting my personal information.
I consent to Special Olympics using my personal information in order to: make sure I am eligible a nd can participate safely; run
trainings and events; share competition results (including on the Web and in news media); provide health treatment if I parti cipate
in a health program; analyze data for the purposes of improving programming and identifying a nd responding to the needs of
Special Olympics participants; perform computer operations, quality assurance, testing, and other related operations and
activities; and provide event-related services.
I consent to Special Olympics using my email address and creating a profile of me for communications and marketing purposes.
I understand that Special Olympics may disclose my personal information to medical professionals in the event of an emergency
and to third party researchers to analyze data for the purposes of improving Special Olympics programming and identifying and
responding to the needs of Special Olympics participants.
I understand that Special Olympics may disclose my personal information to g overnment authorities for the purpose of assisting
me with any visas required for international travel to Special Olympics events and for any other purpose necessary to protect
public safety, respond to government requests, and report information as requir ed by law.
I understand Special Olympics is a global organization with headquarters in the United States of America. I consent to Speci al
Olympics storing and processing my personal information in countries, including the United States of America, that have laws
requiring a different level of privacy and data protection.
I have the right to ask to see my personal information or to be informed about the personal information that is processed about
me. I have the right to ask to make changes to or delete my information.
ATHLETE NAME: _____________________________________________________ Email: ___________________________________
ATHLETE SIGNATURE (required for adult athlete with capacity to sign legal documents)
I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.
Adult Athlete Signature: _______________________________________________________ Date: ____________________________
PARENT/GUARDIAN SIGNATURE (required for athlete who is a minor or lacks capacity to sign legal documents)
I am a parent or guardian of the athlete. I have read and understand this form and have explained the contents to the athlete as appropriate.
By signing, I agree to this form on my own behalf and on behalf of the athlete.
Parent/Guardian Signature: _______________________________________________ Date: ___________________________________
Parent/Guardian Printed Name: ____________________________________________ Relationship: _____________________________
PLEASE PRINT
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Athlete Medical Form – HEALTH HISTORY
(To be completed by the athlete or parent/guardian/caregiver and brought to exam)
ASSOCIATED CONDITIONS - Does the athlete have (check any that apply):
Autism Down Syndrome Fragile X Syndrome
Cerebral Palsy Fetal Alcohol Syndrome
Other Syndrome, please specify:_______________________________________________________________________________
ALLERGIES & DIETARY RESTRICTIONS ASSISTED DEVICES - Does the athlete use (check any that apply):
No Known Allergies Brace Colostomy Communication Device
Latex C-PAP Machine Crutches or Walker Dentures
Medications:_______________________________ Glasses or Contacts G-Tube or J-Tube Hearing Aid
Insect Bites or Stings:_______________________ Implanted Device Inhaler Pacemaker
Food:____________________________________ Removable Prosthetics Splint Wheel Chair
List any special dietary needs:
SPORTS PARTICIPATION
List all Special Olympics sports the athlete wishes to play:
Has a doctor ever limited the athlete’s participation in sports?
No Yes If yes, please describe:
SURGERIES, INFECTIONS, VACCINES
List all past surgeries:
Does the athlete currently have any chronic or acute infection?
No Yes If yes, please describe:
Has the athlete ever had an abnormal Electrocardiogram (EKG) or Echocardiogram (Echo)? If yes, describe date and results
Yes, had abnormal EKG
Yes, had abnormal Echo
Has the athlete had a Tetanus vaccine in the past 7 years? No Yes
FAMILY HISTORY
Has any relative died of a heart problem before age 50? No Yes
Has any family member or relative died while exercising? No Yes
List all medical conditions
that run in the athlete’s family:
Athlete First & Last Name:________________________________________ Preferred Name:_________________________
Athlete Date of Birth (mm/dd/yyyy):__________________________________________ Female Male
STATE PROGRAM:________________________________ E-mail:____________________________________________________
EPILEPSY AND/OR SEIZURE HISTORY
Epilepsy or any type of seizure disorder No Yes
If yes, list seizure type:______________________________________________________________________________________
If yes, had seizure during the past year? No Yes
MENTAL HEALTH
Self-injurious behavior during the past year No Yes Depression (diagnosed) No Yes
Aggressive behavior during the past year No Yes Anxiety (diagnosed) No Yes
Describe any additional
mental health concerns:
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Athlete Medical Form – HEALTH HISTORY
(To be completed by the athlete or parent/guardian/caregiver and brought to Exam )
HAS THE ATHLETE EVER BEEN DIAGNOSED WITH OR EXPERIENCED ANY OF THE FOLLOWING CONDITIONS
Loss of Consciousness No Yes High Blood Pressure No Yes Stroke/TIA No Yes
Dizziness during or after exercise No Yes High Cholesterol No Yes Concussions No Yes
Headache during or after exercise No Yes Vision Impairment No Yes Asthma No Yes
Chest pain during or after exercise No Yes Hearing Impairment No Yes Diabetes No Yes
Shortness of breath during or after exercise No Yes Enlarged Spleen No Yes Hepatitis No Yes
Irregular, racing or skipped heart beats No Yes Single Kidney No Yes Urinary Discomfort No Yes
Congenital Heart Defect No Yes Osteoporosis No Yes Spina Bifida No Yes
Heart Attack No Yes Osteopenia No Yes Arthritis No Yes
Cardiomyopathy No Yes Sickle Cell Disease No Yes Heat Illness No Yes
Heart Valve Disease No Yes Sickle Cell Trait No Yes Broken Bones No Yes
Heart Murmur No Yes Easy Bleeding No Yes Dislocated Joints No Yes
Endocarditis No Yes If female athlete, list date of last menstrual period:____________________
Describe any past broken bones or dislocated joints
(if yes is checked for either of those fields above):
List any other ongoing or past medical conditions:
Neurological Symptoms for Spinal Cord Compression and Atlanto-axial Instability
Difficulty controlling bowels or bladder No Yes If yes, is this new or worse in the past 3 years? No Yes
Numbness or tingling in legs, arms, hands or feet No Yes If yes, is this new or worse in the past 3 years? No Yes
Weakness in legs, arms, hands or feet No Yes If yes, is this new or worse in the past 3 years? No Yes
Burner, stinger, pinched nerve or pain in the neck, back,
shoulders, arms, hands, buttocks, legs or feet No Yes If yes, is this new or worse in the past 3 years? No Yes
Head Tilt No Yes If yes, is this new or worse in the past 3 years? No Yes
Spasticity No Yes If yes, is this new or worse in the past 3 years? No Yes
Paralysis No Yes If yes, is this new or worse in the past 3 years? No Yes
PLEASE LIST ANY MEDICATION, VITAMINS OR DIETARY SUPPLEMENTS BELOW
(includes inhalers, birth control or hormone therapy)
Medication, Vitamin or
Supplement Name
Dosage Times
per Day
Medication, Vitamin or
Supplement Name
Dosage Times per
Day
Medication, Vitamin or
Supplement Name
Dosage Times
per Day
Is the athlete able to administer his or her own medications? No Yes
Name of Person Completing this Form Relationship to Athlete Phone Email
Athlete’s First and Last Name:_______________________________________________________
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Athlete Medical Form – PHYSICAL EXAM
(To be completed by a Licensed Medical Professional qualified to conduct exams & prescribe medications)
MEDICAL PHYSICAL INFORMATION
(To be completed by a Licensed Medical Professional qualified to conduct physical exams and prescribe medications)
Height Weight BMI (optional) Temperature Pulse O2Sat Blood Pressure (in mmHg) Vision
cm kg BMI C BP Right: BP Left: Right Vision
20/40 or better No Yes N/A
in lbs Body Fat % F Left Vision
20/40 or better No Yes N/A
Right Hearing (Finger Rub) Responds No Response Can’t Evaluate
Left Hearing (Finger Rub) Responds No Response Can’t Evaluate
Right Ear Canal Clear Cerumen Foreign Body
Left Ear Canal Clear Cerumen Foreign Body
Right Tympanic Membrane Clear Perforation Infection NA
Left Tympanic Membrane Clear Perforation Infection NA
Oral Hygiene Good Fair Poor
Thyroid Enlargement No Yes
Lymph Node Enlargement No Yes
Heart Murmur (supine) No 1/6 or 2/6 3/6 or greater
Heart Murmur (upright) No 1/6 or 2/6 3/6 or greater
Heart Rhythm Regular Irregular
Lungs Clear Not clear
Right Leg Edema No 1+ 2+ 3+ 4+
Left Leg Edema No 1+ 2+ 3+ 4+
Radial Pulse Symmetry Yes R>L L>R
Cyanosis No Yes, describe
Clubbing No Yes, describe
Bowel Sounds Yes No
Hepatomegaly No Yes
Splenomegaly No Yes
Abdominal Tenderness No RUQ RLQ LUQ LLQ
Kidney Tenderness No Right Left
Right upper extremity reflex Normal Diminished Hyperreflexia
Left upper extremity reflex Normal Diminished Hyperreflexia
Right lower extremity reflex Normal Diminished Hyperreflexia
Left lower extremity reflex Normal Diminished Hyperreflexia
Abnormal Gait No Yes, describe below
Spasticity No Yes, describe below
Tremor No Yes, describe below
Neck & Back Mobility Full Not full, describe below
Upper Extremity Mobility Full Not full, describe below
Lower Extremity Mobility Full Not full, describe below
Upper Extremity Strength Full Not full, describe below
Lower Extremity Strength Full Not full, describe below
Loss of Sensitivity No Yes, describe below
SPINAL CORD COMPRESSION & ATLANTO-AXIAL INSTABILITY (AAI) (Select one)
Athlete shows NO EVIDENCE of neurological symptoms or physical findings associated with spinal cord compression or atlanto-axial instability.
OR
Athlete has neurological symptoms or physical findings that could be associated with spinal cord compression or atlanto-axial instability and
must receive an additional neurological evaluation to rule out additional risk of spinal cord injury prior to clearance for sports participation.
ATHLETE CLEARANCE TO PARTICIPATE (TO BE COMPLETED BY EXAMINER ONLY)
Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to performing the
physical exam. If an athlete needs further medical evaluation please make a referral below and second physician for referral should complete page 4.
This athlete is ABLE to participate in Special Olympics sports without restrictions.
This athlete is ABLE to participate in Special Olympics sports WITH restrictions. Describe ___________________________________________
This athlete MAY NOT participate in Special Olympics sports at this time & MUST be further evaluated by a physician for the following concerns:
Concerning Cardiac Exam Acute Infection O2 Saturation Less than 90% on Room Air
Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly
Other, please describe:
Additional Licensed Examiner’s Notes and Recommended (but not required) Follow -up:
Follow up with a cardiologist Follow up with a neurologist Follow up with a primary care physician
Follow up with a vision specialist Follow up with a hearing specialist Follow up with a dentist or dental hygienist
Follow up with a podiatrist Follow up with a physical therapist Follow up with a nutritionist
Other/Exam Notes:
Name:
E-mail:
Signature of Licensed Medical Examiner Exam Date Phone: License #:
Athlete’s First and Last Name:_______________________________________________
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Athlete Medical Form – MEDICAL REFERRAL FORM
(To be completed by a Licensed Medical Professional only if referral is needed)
This page only needs to be completed and signed if the physician on page three does not clear
the athlete and indicates further evaluation is required.
Athlete should bring the previously completed pages to the appointment with the specialist.
Examiner’s Name:__________________________________________________________________________________
Specialty:_________________________________________________________________________________________
I have been asked to perform an additional athlete exam for the following medical concern(s) - Please describe:
Concerning Cardiac Exam Acute Infection O2 Saturation Less than 90% on Room Air
Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly
Other, please describe:
In my professional opinion, this athlete MAY now participate in Special Olympics sports (indicate
restrictions or limitations below):
Yes Yes, but with restrictions (list below) No
Additional Examiner Notes/Restrictions:
Examiner E-mail: __________________________________________________________________________________
Examiner Phone: __________________________________________________________________________________
License: __________________________________________________________________________________________
Examiner’s Signature Date
This section to be completed by Special Olympics staff only, if applicable.
This medical exam was completed at a MedFest event? Yes No
The athlete is a Unified Partner or a Young Athlete Participant? Unified Partner Young Athlete
Athlete’s First and Last Name:____________________________________________________________