ARcare Sports Physical Form

  • ARcare Sports Physical Form

    (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)
  • Date of Scheduled Exam*
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  • Date of Birth*
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  • Sex
  • Marital Status
  • Language
  • Race/Ethnicity
  • Format: (000) 000-0000.
  • Preferred Method of Contact
  • Guarantor/Guardian DOB
     - -
  • Do you have allergies? (If yes, please indentify specific allergy below.)
  • Has a doctor ever denied or restricted your participation in sports for any reason?
  • Do you have any ongoing medical conditions? If so, please identify below:
  • Have you ever spent the night in the hospital?
  • Have you ever had surgery?
  • Have you ever passed out or nearly passed out DURING or AFTER exercise?
  • Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
  • Does your heart ever race or skip beats (irregular beats) during exercise?
  • Has a doctor ever told you that you have any heart problems? If so, check all that apply:
  • Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)
  • Do you get lightheaded or feel more short of breath than expected during exercise?
  • Have you ever had an unexplained seizure?
  • 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)?
  • 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?
  • Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
  • Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
  • Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
  • Have you ever had any broken or fractured bones or dislocated joints?
  • Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
  • Have you ever had a stress fracture?
  • 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)
  • Do you regularly use a brace, orthotics, or other assistive device?
  • Do you have a bone, muscle, or joint injury that bothers you?
  • Do any of your joints become painful, swollen, feel warm, or look red?
  • Do you have any history of juvenile arthritis or connective tissue disease?
  • Do you cough, wheeze, or have difficulty breathing during or after exercise?
  • Have you ever used an inhaler or taken asthma medicine?
  • Is there anyone in your family who has asthma?
  • Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
  • Do you have groin pain or a painful bulge or hernia in the groin area?
  • Have you had infectious mononucleosis (mono) within the last month?
  • Do you have any rashes, pressure sores, or other skin problems?
  • Have you had a herpes or MRSA skin infection?
  • Have you ever had a head injury or concussion?
  • Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
  • Do you have a history of seizure disorder?
  • Do you have headaches with exercise?
  • Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
  • Have you ever been unable to move your arms or legs after being hit or falling?
  • Have you ever become ill while exercising in the heat?
  • Do you get frequent muscle cramps when exercising?
  • Do you or someone in your family have sickle cell trait or disease?
  • Have you had any problems with your eyes or vision?
  • Have you had any eye injuries?
  • Do you wear glasses or contact lenses?
  • Do you wear protective eyewear, such as goggles or a face shield?
  • Do you worry about your weight?
  • Are you trying to or has anyone recommended that you gain or lose weight?
  • Are you on a special diet or do you avoid certain types of foods?
  • Have you ever had an eating disorder?
  • Do you have any concerns that you would like to discuss with a doctor?
  • Have you ever had a menstrual period?

  • I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

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  • Date
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  • Date
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  • ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
    HE0503 9-2681/0410

  • CONSENT TO TREAT

  • Check one for Consent:
  • If patient is a minor, I give permission for my child to receive an examination and treatment in the absence of adult supervision.
  • If patient is a minor, I give permission for the following individuals (other than parent/legal guardian) to bring my child to the clinic on my behalf. (select at least one)

  • 1. I voluntarily consent to medical care recommended by the clinician including x-rays, heart tracings, medications, and/or routine laboratory testing (including human immunodeficiency virus infection, hepatitis, or any other blood-borne infectious disease if ordered by a clinician for diagnostic purposes). 2. I authorize the clinic to release medical/behavioral health information to insurance carriers for the purposes of filing insurance claims related to my/his/her medical care. 3. I agree that insurance (if applicable) will billed for services and I (patient, parent or guardian of the patient) am responsible for any charges not paid or denied by the insurance company. 4. I understand that even if you have a copy of my Advance Directive or Living Will that clinic staff will attempt to stabilize me and transfer me to an acute care hospital for further evaluation and treatment. 5. I have received the Patient Packet containing ARcare’s Notice of Privacy Practices and my rights about my medical information as a patient of ARcare.

  • Format: (000) 000-0000.
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  • Date
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  • Date
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    TELEMEDICINE CONSENT 

    1. I authorize ARcare/MississippiCare/KentuckyCare to allow me/the patient to participate in a telemedicine/Virtual Care (videoconferencing) service with ARcare. This consent applies to both Physical and Behavioral Health Services. a. If Behavioral Health Services is indicated or requested: I understand that Tele-behavioral health services are completely voluntary and that I can choose not to do or not to answer questions at any time. I understand that I will be assigned one therapist and will only see that that therapist for my behavioral health care via tele-behavioral health services in ensuring continuity of care. I understand that I will be asked to create a safety plan with my therapist in case of an emergency. I understand that if there's an emergency during a Tele-behavioral health session, my therapist will call emergency services and my emergency contacts. 2. The type of service to be provided via telemedicine is Acute Care Services. 3. I understand that this service is not the same as a direct patient/healthcare provider visit, because I/the patient will not be in the same room as the healthcare provider performing the service. I understand that parts of my/the patient’s care and treatment which require physical tests or examinations may be conducted by the clinical staff at my/the patient’s location under the direction of the telemedicine healthcare provider. 4. My/the patient’s physician has fully explained to me the nature and purpose of the videoconferencing technology and has also informed me of expected risks, benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise during the telemedicine session, as well as possible alternatives to the proposed sessions, including visits with a physician in-person. The attendant risks of not using telemedicine sessions have also been discussed. I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. 5. I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation. 6. I understand that the telemedicine session will not be audio or video recorded at any time. 7. I agree to permit my/the patient’s healthcare information to be shared with other individuals for the purpose of scheduling and billing. I agree to permit individuals other than my/the patient’s healthcare provider and the remote healthcare provider to be present during my/the patient’s telemedicine service to operate the video equipment. I further understand that I will be informed of their presence during the telemedicine services. I acknowledge that if safety concerns mandate additional persons to be present, then my/guardian permission may not be needed. 8. I acknowledge that I have the right to request the following: a. The omission of specific details of my/the patient’s medical history/physical examination that is personally sensitive, or b. Termination of the service at any time. 9. When the telemedicine service is being used during an emergency, I understand that it is the responsibility of the telemedicine provider to advise my/the patient’s local healthcare provider regarding necessary care and treatment. 10. It is the responsibility of the telemedicine provider to conclude the service upon the termination of the videoconference connection. 11. I/the patient understand(s) that my/the patient’s insurance will be billed by both the local healthcare provider and the telemedicine healthcare provider for telemedicine services. I/the patient understand(s) that if my insurance does not cover telemedicine services I/the patient will be billed directly by the telemedicine healthcare provider for the provision of telemedicine services. 12. My/the patient’s consent to participate in this telemedicine service for the duration of the specific service identified above, or until I revoke my consent in writing. 13. I/the patient agree that there have been no guarantees or assurances made about the results of this service. 14. I confirm that I have read and fully understand both the above and the Telemedicine: What to Expect Form provided.

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  • HIPAA PRIVACY PRACTICES CONSENT FORM

    We are committed to providing security for patient privacy and confidentiality.  We collect, use, and disclose personal health information only when allowed by state and federal laws and your personal authorization. This may include the collection of other sources of information available, such as medication and prescription history and verification of insurance eligibility.  

    We also understand you may have family members or significant people in your life who you may want to have access to certain information contained in your medical record.  Without your written consent, we cannot release any information to anyone except for purposes outlined in the HIPAA privacy act. Please note that we use an automated phone system to remind you of appointments as well as offer patients the opportunity to complete a survey about their visit. 

    I give permission for those (employees, students, volunteers, contractors, etc.) acting on behalf of the organization to share my protected health information (PHI) with the following specific person(s): (If no other person is authorized to receive your PHI, type N/A in the spaces below.)

     

  • Information to be released:

    [1] Copy of complete health record
    [2] History and physical
    [3] Test results
    [4] Mental health records
    [5] Reproductive health records                            
    [6] Other:  (Use text space to indicate information to be released.)

  • HIPAA RELEASE

    Name of Individual to which information can be released & information to be released.

  • Please enter corresponding # from list of information to be released .

  • Please enter corresponding # from list of information to be released .

  • Please enter corresponding # from list of information to be released .   

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