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The University of Texas at Austin

DIVISION OF SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS

PRE-PARTICIPATION MEDICAL SCREENING FORMS

SPIRIT SQUAD TRY-OUTS

RETURN THIS BOOKLET WITH ALL COMPLETED FORMS DATED AND SIGNED TO:

TEXAS SPIRIT OFFICE 2100 SAN JACINTO, STD 1.246, AUSTIN, TX 78712

DIVISION OF SPORTS MEDICINE INTERCOLLEGIATE ATHLETICS • THE UNIVERSITY OF TEXAS AT AUSTIN

PO Box 7399 • Austin, Texas 78713-7399 Olympic Sports (512) 471-4916 • Football (512) 471-5513 • Fax (512) 232-5054

TO: Try-Out Participants FROM: Allen Hardin, Senior Associate Athletics Director, Sports Medicine SUBJECT: REQUIRED MEDICAL/INSURANCE FORMS This packet contains important forms that you need to complete. Instructions and the purpose of each form, as well as very important information regarding insurance coverage is addressed below. 1. Medical History Questionnaire. This questionnaire is designed to solicit information about your personal health

history and that of your family. It is critical 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 have had a history of previous hospitalizations, surgeries, injuries, or any other conditions that may warrant follow-up medical care. Please be as thorough as you can when answering the questions. The information obtained from the questionnaire will be used by the sports medicine staff to determine your health status.

2. Physical Examination. You must show proof of a physical examination performed by a doctor, completed in

the past 6 months. It is your responsibility to identify a physician who can conduct your physical examination and the complete the form accordingly.

3. Sickle Cell Trait Testing. In Division I Athletics, NCAA legislation has been adopted that requires try out

participants to undergo a sickle cell solubility test unless documented results of a prior test are provided to the institution. Ask your attending physician about where this test can be completed. Try-outs may opt to exercise a waiver declining confirmation of sickle cell trait status. Those individuals that are added to the Spirit Squad must obtain a sickle cell test if prior results are not available, per Texas Athletics Policy.

4. Assumption of Risk/Release and Indemnification Agreement. Participation in intercollegiate athletics

constitutes an assumption of risk because of the vigorous nature of the activities and potential for adverse health consequences. By signing this agreement, you acknowledge that there is an inherent health risk even when all the rules are followed and training conditions are optimal. This is a risk that you accept voluntarily, and therefore, will not hold the Texas Athletics responsible if you get hurt as a direct result of participation.

If you are under 18 years of age, a separate Release and Indemnification Agreement is enclosed that requires the signature of your parent or legal guardian. In addition, if you are under 18 years of age, we must have the consent of your parent or legal guardian to treat you in the event that you sustain an injury or become ill. The form utilized for authorization purposes is entitled Consent for Treatment of a Minor. The signature of your parent or legal guardian grants permission to team physicians, athletic trainers and other health care professionals to provide any preventative, first aid, emergency, or rehabilitative treatment that they deem reasonably necessary for your health and well-being.

5. Notice of Privacy Practices. If you are injured during tryouts, your care will be coordinated by Texas Athletics’ Division of Sports Medicine. The professional staff may disclose your medical information to the extent necessary to provide you with quality medical care. Sharing of this information requires compliance with privacy practices required by law. These privacy practices dictate how your medical information may be used and disclosed, and how you can obtain this information. We are required to provide you with our Notice of Privacy Practices and to secure your signature acknowledging receipt of the privacy notice.

6. Authorizations to Release Medical Information (Coaches and Athletics Staff; Parents and Guardians;

Media; Teammates; Student Athletic Trainers and Other Student Members of Sports Medicine Staff; and Professional Teams). The Division of Sports Medicine has policies and procedures in place to safeguard the privacy of your medical records and protect you from unnecessary disclosure of your health information. In an

athletics setting, there are many parties who may potentially have access to your health information, especially in routine injury situations. These parties include coaches and athletics staff; parents or guardians; media; teammates; athletic training students; and, professional teams and their scouts.

In the event that you sustain an injury while trying out, we may need to discuss with your coaches, parents, and/or other people involved in your care to best determine your treatment options. When doing so only within the following parameters: • You have given us oral consent or implied consent through your actions. • You have signed authorization forms permitting us to disclose pertinent health information to the parties

mentioned.

You have the right to restrict disclosure of your health information to any of the 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 validate with your signature and date. You maintain the right to revoke any of your signed authorizations. In order for you to revoke your signed authorizations under these circumstances, you must discuss your intentions with your providers (e.g., team physicians and athletic trainers) and a new form will be processed that restricts disclosure of the specified health information.

Although you have signed authorizations permitting us to share your health information, 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 information necessary to protect your health and safety, and we will take appropriate measures to ensure the confidentiality of your medical records.

7. Authorization for Release of Insurance Data. Texas Athletics cannot assume financial responsibility for treatment if you are injured during the tryout period. Therefore, you are required to indicate the type of insurance coverage that you possess or that is maintained for you by your parents/guardians. You will not be cleared for participation if you do not have insurance coverage and/or if you fail to provide all the information requested.

8. Authorizations for Release of Your Patient Records. Upon receipt of your medical screening forms, the sports

medicine staff will thoroughly review your Report of Medical History, with special attention to information regarding current medications, precious hospitalizations and/or surgeries, and injuries/illnesses that warranted a physician’s care.

In the event your medical history is consistent with one or all of the above conditions, we may need additional medical information from your physician(s). The Medical Records Release form is included in this packet for this purpose. Your signature is required to secure additional medical records. Complete only the bottom portion of this form that requests your signature and date.

9. Disclosure of ADD/ADHD Medications. Certain medications, specifically stimulant medications (e.g.,

Strattera, Ritalin, Adderall, etc.) for the treatment of “attention deficit disorder” or ADD/ADHD, must be declared at the time of your pre-participation screening. Therefore, all participants prescribed stimulant medications for ADD/ADHD must provide adequate documentation of diagnosis and medication prescription. Your prescribing physician must complete the forms in the section entitled Documentation for Stimulant Medications. Tear out these forms in this section and forward them to your prescribing physician for completion. Your physician must complete these forms as instructed and return the documents to us.

Circle questions you don’t know the answers. Explain “YES” answers.



I. Report of Medical History

Name Phone/Cell

Address City, State, Zip

UTEID (if one has been assigned)

Sex Age DOB

Year at UT (check): Incoming Freshman Freshman Sophomore Junior Senior

Sport(s) Position/Event

Personal Physician Phone

In case of emergency, contact: Name Relationship

GENERAL QUESTIONS Yes No EXPLANATION

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 Yes No EXPLANATION

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?

Medicines: 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 If YES, please identify specific allergy: Pollens Stinging Insects Food

Report of Medical History, page 2


HEART HEALTH QUESTIONS ABOUT YOU (continued)

Yes No EXPLANATION

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No EXPLANATION

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?

BONE AND JOINT QUESTIONS Yes No EXPLANATION

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:

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 Yes No EXPLANATION

26. Do you cough, wheeze, or have difficulty breathing during or after exercise?

27. Have you ever used an inhaler or taken asthma medicine?

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?



MEDICAL QUESTIONS (continued) Yes No EXPLANATION

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?

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?



FEMALES ONLY Yes No EXPLANATION

59. Have you ever had a menstrual period?

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

61. How old were you when you had your first menstrual period?

AGE

62. When was your most recent menstrual period? Date

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? # 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

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

```````````````````````````````````````````````````````````````````````````````````````````````

Reviewed by James Bray, MD Jessica Zarndt, DO Athletic Trainer

Date Any changes since the questionnaire was completed? Yes No

Preparticipation Physical Examination: UT Division of Sports Medicine

PHYSICIAN REMINDERS 1. Consider additional questions on more sensitive issues:

● Do you feel stressed out or under a lot of pressure? ● Do you ever feel sad, hopeless, depressed, or anxious? ● Do you feel safe at your home or residence? ● Have you ever tried cigarettes, chewing tobacco, snuff, or dip? ● During the past 30 days, did you use chewing tobacco, snuff, or dip? ● Do you drink alcohol or use any other drugs? ● Have you ever taken any supplements to help you gain ● Have you ever taken anabolic steroids or used any other performance supplement?

or lose weight or improve your performance? ● Do you wear a seat belt, use a helmet, and use condoms? ● Do you practice safe sex? ● Do you have a history of any sexually transmitted infections?

2. Consider reviewing questions on cardiovascular symptoms (questions 5-14). EXAMINATION Height Weight Male Female

BP / ( / ) Pulse Vision R20 L 20 Corrected Y N

MEDICAL NORMAL ABNORMAL FINDINGS Appearance ● Marfan stigma (kyphoscoliosis, high-arched palate, pectus excavatum,

arachnodactyly, arm span > height, hyperfaxity, 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 Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. b Consider GU exam if in private setting. Having third party present is recommended. c 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).

Physician’s Name James Bray, MD Jessica Zarndt, DO Other _

Address Phone

Physician’s Signature , MD or DO Date

© 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,

Revised 08/19/2015

Name Sport

UTEID Date of Birth

15.12.1a(9-10-2015)

Sports Medicine, Policy and Procedural ManualThe University of Texas at Austin

DIVISION OF SPORTS MEDICINE Department of Intercollegiate Athletics ● The University of Texas at Austin

P.O. Box 7399 • Austin, Texas 78713 Olympic Sports (512) 471-4916 • Football (512) 471-5513 • Fax (512) 232-5054

AboutSickleCellTrait Sickle cell trait is not a disease. Sickle cell trait is an inherited condition affecting the oxygen-

carrying substance, hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like a disease.

Sickle cell trait is a common condition (> 3 million Americans). Although Sickle cell trait occurs most commonly in African-Americans and those of Mediterranean,

Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this condition.

Those with sickle cell trait usually have no symptoms or any significant health problems. However, sometimes during very intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in those with sickle cell trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden collapse and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3 continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning training. Extreme heat and dehydration increase the risks.

More information and resources regarding sickle cell trait and the NCAA’s recommendation for sickle cell trait testing can be found at the NCAA web site resource pages regarding the sickle cell trait, accessible at: www.NCAA.org/health‐safety.

SickleCellTraitTesting The NCAA recommends that all student-athletes have knowledge of their sickle cell trait status.

Student-athletes must 1) show proof of a prior test with results; 2) have a blood test to check for sickle cell trait; or 3) sign a testing waiver declining options 1 and 2. Whichever option is chosen, it must be completed before the athlete participates in any intercollegiate athletics event, including strength and conditioning sessions, practices, competitions, etc.

Texas Athletics recommends that all student-athletes who are unable to confirm their sickle cell trait status undergo sickle cell trait testing prior to participation in any intercollegiate athlete activity.

Athletes who are positive for the trait will be allowed to participate in intercollegiate athletics; this does NOT prohibit you from playing.

Oneofthefollowingthreeoptionsmustbechosen:

□ Copy of athlete’s newborn sickle cell testing resultattached. Date: □ Copy of recent sickle cell screening test resultattached. Date: □ Completed Sickle Cell Testing Waiver (see next page)

SICKLE CELL TRAIT INFORMATION & REQUIREMENT

Sports Medicine, Policy and Procedural ManualThe University of Texas at Austin

15.12.1a(9-10-2015)

DIVISION OF SPORTS MEDICINE

Department of Intercollegiate Athletics ● The University of Texas at Austin P.O. Box 7399 • Austin, Texas 78713

Olympic Sports (512) 471-4916 • Football (512) 471-5513 • Fax (512) 232-5054

I understand and acknowledge that the NCAA recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I attest that I have read and fully understand the educational materials provided to me regarding the risks, impact, and precautions associated with sickle cell trait, and I have had the opportunity to review the NCAA website for further information about sickle cell trait and sickle cell trait testing.

Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to Texas Athletics.

I do not wish to undergo sickle cell trait testing at this time and I voluntarily agree to release, discharge, indemnify and hold harmless The University of Texas, its officers, employees, agents and their successors and assigns from any and all costs, claims, damages or expenses, including attorneys fees, arising from any loss or personal injury that might result from my refusal to be tested.

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, the Board of Regents of the University of Texas System, the University of Texas System, and their officers, employees, or agents (hereinafter referred to as Releasees) 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 Releases from liability for the injury or death of any person(s) and 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

Signature of Parent/Guardian (if under 18 years of age) Date

SICKLE CELL TRAIT TESTING WAIVER FOR TRY-OUTS

Minor Apvd. by UT Austin Legal, JG, 07/16/2010

Revised 08/19/2015



PARTICIPANT’S NAME SPORT

The University of Texas at Austin’s Departments of Intercollegiate Athletics is concerned about the health and well-being of its prospective student-athletes. However, the health status and physiological capabilities of individuals who are not recruited student-athletes at the time of team tryouts are not known to the University’s athletics personnel or sports medicine providers. Therefore, it is necessary for any UT student desiring to tryout for an intercollegiate athletics team to certify that he/she is in adequate physical condition to meet training expectations, 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 am fully competent to sign this Agreement.

I realize that my son’s/daughter’s participation in the aforementioned sport 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 participant’s 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.

I acknowledge that my son’s/daughter’s 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 son’s/daughter’s 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 tryout. I understand that The University of Texas at Austin and all its insurers will not be

ASSUMPTION OF RISK/RELEASE AND INDEMNIFICATION AGREEMENT

(Applicable only if participant is under 18 years of age)

Minor Apvd. by UT Austin Legal, JG, 07/16/2010

Revised 08/19/2015

Authorization of Risk/Release and Indemnification Agreement, page 2

responsible for any of my son’s/daughter’s 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 he/she may suffer during participation. 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 son’s/daughter’s 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 Address (if different than Participants)

Signature of Witness (over 21 years of age) Date Signed

Adult Apvd. by UT Austin Legal, JG, 07/16/2010

Revised 08/19/2015



PARTICIPANT’S NAME SPORT

The University of Texas at Austin’s Departments of Intercollegiate Athletics is concerned about the health and well-being of its prospective student-athletes. However, the health status and physiological capabilities of individuals who are not recruited student-athletes at the time of team tryouts are not known to the University’s athletics personnel or sports medicine providers. Therefore, it is necessary for any UT student desiring to tryout for an intercollegiate athletics team to certify that he/she is in adequate physical condition to meet training expectations, 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 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 participant’s 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.

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 employed to minimize my risk of sustaining an injury/illness while participating in the sport. 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 any and all liability, claims, costs or expenses resulting from any and all injuries (including death) or infirmities that I may suffer in the course of my 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/infirmity that I may suffer during my participation. I further agree to

ASSUMPTION OF RISK/RELEASE AND INDEMNIFICATION AGREEMENT

Adult Apvd. by UT Austin Legal, JG, 07/16/2010

Revised 08/19/2015

Authorization of Risk/Release and Indemnification Agreement, page 2

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 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



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 Date Signed

Minor Revised 08/19/2015

CONSENT FOR TREATMENT OF A MINOR

(Applicable only if student-athlete is under 18 years of age)

Sports Medicine, Policy and Procedure Manual The University of Texas at Austin

THE UNIVERSITY OF TEXAS AT AUSTIN DIVISION OF SPORTS MEDICINE 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 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-athlete’s 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.

• Worker’s 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.


• 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.

V. 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.


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. 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 Athletics Risk Management and Compliance Services at (512) 471-7285.

Revised 08/19/2015



NOTICE OF PRIVACY PRACTICES

STUDENT-ATHLETE ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the

(print name) Notice of Privacy Practices of the Intercollegiate Athletics Division of Sports Medicine at The University of Texas at Austin.

Date:

Signed:

Signed: (If student is under 18 years of age, parent’s/guardian’s signature)

Apvd. by UT Austin Legal, JG, 2004, 05/28/2010 Revised 08/19/2015




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 in athletics 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 student-athlete. 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 Director of the Division of 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.

Signature of Student-Athlete Date

Signature of Parent/Legal Guardian Date (If student-athlete is under 18 years of age)

AUTHORIZATION – RELEASE OF MEDICAL INFORMATION TO PARENTS

OR GUARDIAN





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 the media including specifically UT’s 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 that they may be reported on accurately while I am a student athlete. 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.





AUTHORIZATION – RELEASE OF MEDICAL INFORMATION TO THE MEDIA





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 compete while I am a student athlete. 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 medical treatment. I may inspect or copy any information used/disclosed under this authorization.




AUTHORIZATION – RELEASE OF MEDICAL INFORMATION TO COACHES

AND ATHLETICS STAFF





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 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 that they will 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.





AUTHORIZATION – RELEASE OF MEDICAL INFORMATION TO TEAMMATES



Post Office Box 7399 • Austin, Texas 78713-7399 Olympic Sports (512) 471-4916 • Football (512) 471-5513 • Fax (512) 232-5054


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 sports medicine healthcare. 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 allow such student athletic trainers and other students participating in the delivery of sports medicine healthcare to assist and participate in the provision of healthcare to me while I am a student athlete. 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 medical treatment. I may inspect or copy any information used/disclosed under this authorization.




AUTHORIZATION – RELEASE OF MEDICAL INFORMATION TO STUDENT ATHLETIC TRAINERS AND OTHER STUDENT MEMBERS OF THE SPORTS

MEDICINE STAFF

Revised 08/19/2015



University of Texas students seeking to try out for Intercollegiate Athletics teams can do so only when the following requirements have been met: (1) provides proof of insurance coverage; (2) completes release of liability and authorization forms; (3) completes a medical history questionnaire; (4) provides documentation of physician clearance; and (5) provides laboratory documentation of sickle cell trait status.

Name of Participant Sport (please print)

I, the above-named participant, am eighteen years of age or older and have requested to try out for an Intercollegiate Athletics team. I understand that there is no insurance coverage provided by UT Athletics for injuries/illnesses of any nature incurred in team practices or transportation to such practices during the try-out period. I must show proof of insurance coverage to be granted permission to try-out.

I am covered by my family insurance policy or individual insurance I purchased . I have completed the insurance questionnaire enclosed in this packet indicating the specifics of my coverage. I acknowledge that I am required 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 of any changes in my coverage, and (3) I may be subject to suspension from participation and be solely responsible for medical expenses from any injuries/illnesses incurred during a period in which my coverage lapses.

I also understand that my insurance policy must not exclude coverage for injuries sustained from participation in intercollegiate athletics. If such exclusions exist in my policy, I acknowledge that I will be solely responsible for all expenses associated with all injuries sustained while participating. It is my responsibility to determine if my insurance coverage meets this requirement.

I am signing this agreement voluntarily and with complete understanding of the terms and conditions contained herein.

Participant’s Signature UTEID

Date of Signature

INSURANCE AUTHORIZATION:

TRYING OUT FOR INTERCOLLEGIATE ATHLETICS TEAMS

Revised 08/19/2015



INSURANCEQUESTIONNAIRE

This form MUST be completed, signed, and returned before you will be allowed to participate on a varsity intercollegiate athletics team at The University of Texas at Austin. A new form must be complete EVERY year.

SECTION I: MEDICAL SERVICE INSURANCE AGREEMENT – I acknowledge receiving the UT-Austin Athletics’ insurance procedural letter. I understand the extent of The University’s 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/activity.

Gender: M F

Print Name Student-Athlete’s Signature Date Birth Date: Marital Status: S M UTEID: Sport: Cell Phone #: Your Email:

Permanent Address City, State, Zip (Providence, Country, Postal Code) Emergency Contact Phone/Cell

SECTION II: POLICYHOLDER INFORMATION (Please Print) Policyholder’s (PH) Name: PH DOB: PH Gender: M F

Student-Athlete’s Relationship to PH: Child Spouse Self Other:

PH’s Address: Primary Residence? Yes No Home Ph.#: Cell Ph. #:

Home Email: Employed Retired Unemployed

Is Ins. Thru Employer? Yes No Employer: Employer Phone #: Fax #: Employer’s Address: Work Email:

SECTION III: HEALTH INSURANCE INFORMATION (Please Print)

Insurance Company: Policyholder’s 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 Policyholder’s ID #: Benefits Phone #: RXBIN# RXGrp# Claims Mailing Address: Dental Insurance Co.: NO Dental Insurance Policyholder’s ID #: Benefits Phone #: Group# Plan Payer ID# Claims Mailing Address:

Front and back copies of medical, prescription, dental & vision cards MUST BE attached to this form. Also, you may fax to (512)232-5054 or scan as an email to [email protected].

mailto:[email protected]

Revised 08/19/2015



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 intercollegiate athletics 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 intercollegiate sport 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 son’s/daughter’s medical or patient accounting records to my insurance company and/or to The University.

Name of Student-Athlete (please print) UTEID (if one has been assigned)

Student-Athlete’s Signature Date Date of Birth

Parent/Guardian’s 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.

AUTHORIZATION TO RELEASE UT INSURANCE DATA

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 or guardians will have to sign for you.



Athlete’s Name: DOB: UTEID:

I authorize information released from my home based physician, to:

Dr. James Bray, Head Team Physician (FAX: 512/232-5054) Purpose of Release (please check box): Division Athletic Training/Sports Medicine Changing Primary Care Physician/Clinic Intercollegiate Athletics Referral/Consultation The University of Texas at Austin Insurance Post Office Box 7399 Legal Austin, Texas 78713-7399 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 Sexually Transmitted Diseases Initial Initial Alcoholism Diagnosis/Treatment AIDS/HIV Test Results Including Related High Risk Behavior Initial Initial Mental Health/Treatment Genetic Testing Initial 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 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

Revised 08/19/2015

MEDICAL RECORDS RELEASE: PROVIDERS

Documentation for Stimulant Medications (Strattera, Ritalin, Adderall, etc.)

If you are currently taking stimulant medications, we request that you tear out the paperwork on the following pages – Letter to Health Care Provider and ADD/ADHD Form – and forward it to your prescribing physician for completion and subsequent return to us.



Dear Health Care Provider:

Your patient is a try-out for the Spirit Squad at The University of Texas at Austin. The National Collegiate Athletics Association (NCAA) requires that all athletes on stimulant medication for the treatment of ADD/ADHD provide adequate documentation of diagnosis and prescription medication. The Division of Sports Medicine, Intercollegiate Athletics is requesting you provide the following information on behalf of your patient.

Please complete the enclosed form for your patient. In completing this paper work, you acknowledge that you have reviewed the patient’s health history and have informed the patient at some time of the safety information and guidelines for stimulant use as well as education regarding the dangers of misuse. In addition, if this student-athlete has failed non-stimulant treatment (Strattera, etc.), please document this as well in the spaces provided. Please attach any consult letters or SOAP notes that may clarify the patient’s diagnosis and the need to use stimulant medications for treatment.

Please send documentation to: James Bray, M.D.

Head Team Physician Sports Medicine Intercollegiate Athletics The University of Texas at Austin P. O. Box 7399, Austin, TX 78713-7399

Thank you for taking time for providing the requested information. We greatly appreciate your assistance.

Sincerely,

Allen Hardin, PT, MS, SCS, ATC, LAT, CSCS Senior Associate Athletics Director, Division of Sports Medicine Intercollegiate Athletics, The University of Texas at Austin

Revised 08/19/2015



DOCUMENTATION OF ADD / ADHD MEDICATIONS

Patient/ Student-Athlete: DOB: Date:

Date of Most Recent Clinical Evaluation: ADHD Evaluation Components: Comprehensive clinical evaluation (using DSM-IV criteria) Adult ADHD Rating Scale Score

(e.g., Adult ADHA self report scale (ASRS) CONNER’S Adult ADHA reporting scale (CAARS)

Monitored blood pressure and pulse

Comments:

Alternative non-banned medications have been considered

**Please submit copies of test results for the medical record **

Additional ADHD Evaluation Components: Reporting of ADHD Symptoms by Other Significant Individual(s): Other Psychological Testing: Physical Exam Date: Results: Laboratory/Testing: Previous Documentation of ADHD Diagnosis: Other/Comments (such as if non-stimulants failed and dates of trials):

DX: MED(S) & DOSAGE:

DX: MED(S) & DOSAGE:

The student-athlete will follow-up with me in (circle one) 3 months, 6 months, 12 months, other: Physician Name printed: Date: Physician Signature Specialty: (MD or OD) Office Address: Contact #:

Please feel free to attach any clinical SOAP notes that may help clarify your patient/our athlete’s diagnosis of ADD/ADHD and the need for stimulant medications. Thank you for your attention to this matter.

Student-Athlete: Please complete the following: I, ,student-athlete, give (treating provider) permission to release all information regarding my treatment for ADD/ADHD to The University of Texas at Austin Division of Sports Medicine. This authorization will be valid for one calendar year beginning on the date I sign this authorization. I may revoke this authorization at any time by submitting a letter in writing to the Director of the Division of Sports Medicine, understanding that all information released prior to my revocation is excluded.

My signature below indicates that I have read and understand the above statement

Signature: Date:

Parent’s/Guardian’s Signature: Date: (if under 18 years of age)

Revised 08/19/2015

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