ARcare CC Sports Physical Form 2024

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*

MonthDayYear
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Sex

MaleFemale
Grade*
School District*
Sport(s)
Marital Status

SingleMarriedDivorcedWidowed
Language

EnglishSpanishOther
Race/Ethnicity

WhiteAfrican AmericanLatinoSpanishOther
Parent Phone
Parent Email
example@example.com
Preferred Method of Contact

PhoneEmailTextAllOther
Primary Care Provider (PCP)
Guarantor/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guarantor/Guardian DOB

MonthDayYear
Date
Medicines &Allergies: Please list all prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking.
Do you have allergies? (If yes, please indentify specific allergy below.)

YesNoMedicinesPollensFoodStinging Insects
Has a doctor ever denied or restricted your participation in sports for any reason?

YesNo
Do you have any ongoing medical conditions? If so, please identify below:

AshtmaAnemiaDiabetesInfectionsOther
Have you ever spent the night in the hospital?

YesNo
Have you ever had surgery?

YesNo
If yes, please list surgery and date
Have you ever passed out or nearly passed out DURING or AFTER exercise?

YesNo
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

YesNo
Does your heart ever race or skip beats (irregular beats) during exercise?

YesNo
Has a doctor ever told you that you have any heart problems? If so, check all that apply:

YesNoHigh Blood PressureHigh CholesterolKawasaki DiseaseHeart MurmurHeart InfectionOther
Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

YesNo
Do you get lightheaded or feel more short of breath than expected during exercise?

YesNo
Have you ever had an unexplained seizure?

YesNo
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)?

YesNo
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?

YesNo
Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

YesNo
Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

YesNo
Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?

YesNo
Have you ever had any broken or fractured bones or dislocated joints?

YesNo
Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

YesNo
Have you ever had a stress fracture?

YesNo
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)

YesNo
Do you regularly use a brace, orthotics, or other assistive device?

YesNo
Do you have a bone, muscle, or joint injury that bothers you?

YesNo
Do any of your joints become painful, swollen, feel warm, or look red?

YesNo
Do you have any history of juvenile arthritis or connective tissue disease?

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

YesNo
Have you ever used an inhaler or taken asthma medicine?

YesNo
Is there anyone in your family who has asthma?

YesNo
Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

YesNo
Do you have groin pain or a painful bulge or hernia in the groin area?

YesNo
Have you had infectious mononucleosis (mono) within the last month?

YesNo
Do you have any rashes, pressure sores, or other skin problems?

YesNo
Have you had a herpes or MRSA skin infection?

YesNo
Have you ever had a head injury or concussion?

YesNo
Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

YesNo
Do you have a history of seizure disorder?

YesNo
Do you have headaches with exercise?

YesNo
Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

YesNo
Have you ever been unable to move your arms or legs after being hit or falling?

YesNo
Have you ever become ill while exercising in the heat?

YesNo
Do you get frequent muscle cramps when exercising?

YesNo
Do you or someone in your family have sickle cell trait or disease?

YesNo
Have you had any problems with your eyes or vision?

YesNo
Have you had any eye injuries?

YesNo
Do you wear glasses or contact lenses?

YesNo
Do you wear protective eyewear, such as goggles or a face shield?

YesNo
Do you worry about your weight?

YesNo
Are you trying to or has anyone recommended that you gain or lose weight?

YesNo
Are you on a special diet or do you avoid certain types of foods?

YesNo
Have you ever had an eating disorder?

YesNo
Do you have any concerns that you would like to discuss with a doctor?

YesNo
If you answered "Yes" to any of the questions above, please explain here.
Have you ever had a menstrual period?

YesNo
How old were you when you had your first menstrual period?

N/AAge
How many periods have you had in the last 12 months?

N/ANumber
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Athlete Signature*

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
©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:

I am the pateint.Patient is a minor.Patient is an adult who cannot act on his/her own.Other
If patient is a minor, what is the patient's age?
If patient is a minor, I give permission for my child to receive an examination and treatment in the absence of adult supervision.

YesNo
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)

NoneSchool StaffClinic StaffDaycare StaffOther (List here)
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.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Signature of patient or Guardian

Clear
Date

MonthDayYear
Date
Signature of staff who explained the contents of consent

Clear
Date

MonthDayYear
Date
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.
Signature of patient or guardian*

Clear
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.
Name

First NameLast Name
Please enter corresponding # from list of information to be released blank .
Name

First NameLast Name
Please enter corresponding # from list of information to be released blank .
Name

First NameLast Name
Please enter corresponding # from list of information to be released blank .
Signature of patient or guardian

Clear
Should be Empty:

ARcare Sports Physical Form