UC Irvine Sports Medicine IMPORTANT DATES AND INFORMATION REGARDING

PRE-PATICIPATION PHYSICAL EXAMS

If you have any questions regarding this information, please call UC Irvine Sports Medicine at (949) 824-2876 OR (949) 824-1041

Dear Student-Athlete,

Welcome to UC Irvine! We commend you on your academic and athletic success and we are happy you are here. Prior to obtaining your Athletic Medical Screen and Clearance by our Team Physicians, you MUST HAVE ALL PAPERWORK COMPLETED AND TURNED IN. Medical clearance to participate will not be scheduled with our Team Physician if paperwork is incomplete! Please see the information below for the appropriate medical clearance date and time.

Please note: If you have a complex medical history or if you have had a recent orthopedic problem, you must bring a copy of your medical record documentation for our team physicians to review. Incomplete documentation will delay final medical clearance for participation.

Location: Gottschalk Medical Plaza 1 Medical Plaza Drive Irvine, CA 92617

AUGUST 3, 2019 – SATURDAY Physical paperwork due by July 15, 2019 7:30 AM Women’s Basketball

Women’s Soccer Men’s Soccer

8:00 AM Women’s Volleyball 8:30 AM Men’s Basketball

Men’s Golf Women’s Golf

AUGUST 10, 2019 – SATURDAY Physical paperwork due by July 22, 2019 7:30 AM Women’s Water Polo 8:00 AM Men’s Water Polo

Men’s Volleyball 8:30 AM Cross Country 9:00 AM Cheer and Dance

SEPTEMBER 21, 2019 – SATURDAY Physical paperwork due by September 2, 2019 7:30 AM Baseball 8:00 AM Track and Field 8:30 AM Women’s Basketball Scout 9:00 AM Men’s Tennis

Women’s Tennis

We look forward to hearing from you. We wish you the best of luck on your academic and athletic endeavors. Sincerely,

UC Irvine Sports Medicine Staff

PLEASE RETURN ALL MEDICAL PAPERWORK TO UC IRVINE SPORTS MEDICINE (with this page as cover sheet)

Fax to (949) 824-1091 ATTENTION: UC Irvine Sports Medicine

Mail to UC Irvine Sports Medicine Re: Student-Athlete Clearance Forms 103 Intercollegiate Athletics Building Irvine, CA 92697-4500

Athlete's Name: ____________________________________________________________________________________________________

Sport(s):___________________________ Date:__________________________________ Total Pages (including this sheet): ___________

Incoming Athletes (Freshmen and Transfers) MUST complete:

I have enclosed with this Fax or Mailing (or Hand Delivery) to UC Irvine Sports Medicine (Initial _______) Athlete/Parent Emergency Contact & Insurance Information Copy of front and back of insurance card(s) Athletic Participation History Questionnaire Physical Examination Record Copy of Immunization Record Sickle Cell Result ADHD Documentation (if applicable) Authorization for Release of Health Information to University Student Health Services Authorization for Release of Health Information to UC Irvine Sports Medicine Authorization for Release of Health Information to Media Authorization for Medical and/or Psychological Treatment of a Minor (under 18yrs)

I have created an account on SportsWare online (swol123.net) and fully completed the following: (Initial _______) Emergency Contact Insurance Form Copy of front and back of insurance card(s)

I will log onto ARMS immediately after the compliance meeting at UC Irvine where I will read and acknowledge the educational material regarding: (Initial _______) *** Final clearance for participation will be withheld until completed.***

HIPPA Concussion Sickle Cell Heat Illness USHIP

UC Irvine Sports Medicine ATHLETE/PARENT EMERGENCY CONTACT

AND INSURANCE INFORMATION

Page 1 of 2

Athlete's Name: ______________________________________ Date of Birth: ______________ UCI Student ID #:_________________

Sport(s):___________________________ Year: 1 2 3 4 5 Cell Phone #: __________________________________________

In case of emergency notify: Name: ______________________________ Relationship:_____________________ Phone: ___________________________ Dear Parent(s)/Guardian of student athletes: • DO NOT Drop dependent coverage while your son or daughter is participating in intercollegiate athletics. Primary insurance is MANDATORY for all UC Irvine

Students while participating in athletics. • In all injury or illness cases, UC Irvine Athletics will use the student-athlete’s primary insurance. • UC Irvine Athletics carries a secondary insurance policy in "EXCESS" or "SECONDARY" to all other collectible insurance benefits.

o Provides coverage additional to the student-athletes’ primary insurance for injuries which occurred while participating in intercollegiate sport practice or play under the direct supervision of a UC Irvine coach.

o Does not cover student-athletes participating in unsupervised sport related activities. o Eligibility of coverage must be authorized in writing by the Director of Sports Medicine. o Is not all inclusive and will only cover costs deemed reasonable and customary by the insurance provider. o May have limitations that define the scope of care.

Additional note: The UC Student Health Insurance Plan (USHIP) is offered through UC Irvine Student Health and every student is automatically enrolled. We recommend student-athletes not waive out of USHIP and utilize quick and easy campus access for routine health care. Exclusions and restrictions in USHIP typically make the primary insurance health care plan superior, for more complex health care needs. The exception is the international student-athlete. Most employers’ group insurance allows dependent coverage to be continued until age 26. If enrolled in USHIP for the fall quarter, this policy will not be active and cover any medical related costs until after the start of the academic quarter. Have you WAIVED your enrollment in UC Student Health Insurance Plan (USHIP) from UC Irvine Student Health by the September 9, 2019 Deadline? You must waive out yearly at www.shs.uci.edu/, current yearly fee is $1893.87. YES NO PLEASE COMPLETE FULLY, SIGN THE BOTTOM & RETURN TO UC IRVINE SPORTS MEDICINE

Athlete: UCI Local Address (If known) __________________________________________City/State _______________________ Zip _____________ School email ______________________________________________________________________________________________________ Father/Guardian: Name (last, first) ______________________________________ DOB ________________________________________________ Home Address ________________________________________ City/State __________________________ Zip ______________ Home Phone __________________________________________ Cell Phone ___________________________________________

Mother/Guardian: Name (last, first) ______________________________________ DOB ________________________________________________ Home Address ________________________________________ City/State __________________________ Zip ______________ Home Phone __________________________________________ Cell Phone ___________________________________________

Primary Insurance: Please include a copy of Insurance Cards (front & back). Company: ___________________________________________ City/State : _______________________ Zip ________________ Plan/Group #: ________________________________________ Subscriber Name: ______________________________________ Subscriber’s Employer: _________________________________ City/State: ________________________ Zip:_______________

Insurance Address: ____________________________________ Insurance Phone: _____________________________________ Policy/Member ID#: ___________________________________ Subscriber ID#: _______________________________________ Employers’ Address: ___________________________________ Is this insurance: HMO PPO POS EPO Indemnity

Is student athlete covered under any DENTAL INSURANCE POLICY? YES NO Is student-athlete covered under any VISION INSURANCE POLICY? YES NO I acknowledge I have read this form in its entirety. I hereby certify that the information above is true, complete, and correct to the best of my knowledge. If there are changes in coverage or an expiration of coverage, I agree to notify UCI Athletics Sports Medicine and update the insurance information on file and on SportsWare Online. I agree, should it be determined at a later date, that I have not accurately informed UC Irvine of collectible coverage, I will reimburse UC Irvine or its insurance company.

__________________________________________________ Parent/Guardian Signature and Date (Required Regardless of Athlete’s Age)

____________________________________________________ Student-Athlete Signature and Date

UC Irvine Sports Medicine ATHLETE/PARENT EMERGENCY CONTACT

AND INSURANCE INFORMATION

Page 2 of 2

Information regarding Primary Care Physician (PCP) / Medical Group: UCI Gottschalk Medical Plaza is located on campus directly across the street from the Carlos A. Prietto, MD Sports Medicine Center at Crawford Hall. Several of our Team Physicians are on the medical school faculty and see private patients at the UCI Medical Plaza. We highly recommend that you consider changing your Primary Care Physician (PCP) on your medical insurance plan to a physician listed below, after confirming they are part of your plan. This will create convenience for prompt medical care during the school year and allow our physicians to facilitate your care. If your insurance does not include UCI Medical Center as part of your plan, we have other recommendations for PCP in the area. If you have questions about this, please contact the sports medicine center staff for further information. Team Physicians and UCI Medical Plaza / UCI Medicine Center & Medical School Faculty / Physicians Brian Kim, MD Assistant Clinical Professor – Primary Care Sports Medicine & Family Medicine Christopher Kroner, MD Assistant Clinical Professor – Primary Care Sports Medicine & Family Medicine Dean Wang, MD Assistant Clinical Professor – Orthopaedic Surgery & Sports Medicine Team Physicians not directly affiliated with UC Irvine Medical Center. Additional options for your insurance plan and have strong sports medicine backgrounds and work with UC Irvine Athletics. Michael Shepard, MD Orthopedic Surgeon & Sports Medicine – Orthopaedic Specialty Institute, Irvine & Orange Robert Grumet, MD Orthopedic Surgeon & Sports Medicine – Orthopaedic Specialty Institute, Irvine & Orange Brent Davis, MD Orthopaedic Surgeon & Sports Medicine - Kaiser Orange County Team Physicians & UC Irvine Student Health Services (USHIP Insurance Providers) Hien Nghiem, MD Primary Care Sports Medicine & Family Medicine, UCI Student Health Henry Tsai, MD Primary Care Sports Medicine & Internal Medicine, UCI Student Health

If the primary insurance policy DOES restrict the medical providers the student-athlete may use, please enter the corresponding policy information below:

The Primary Care Physician/ Medical Group is: ________________________________________________________________________ PCP/ Medical Group: _______________________________________________________Phone #: _______________________________ Address, City, Zip Code: ___________________________________________________________________________________________ Secondary Insurance: Please include a copy of Insurance Cards (front & back). Company: ___________________________________________ City/State : _______________________ Zip ________________ Plan/Group #: ________________________________________ Subscriber Name: ______________________________________ Subscriber’s Employer: _________________________________ City/State: ________________________ Zip:_______________

Insurance Address: ____________________________________ Insurance Phone: _____________________________________ Policy/Member ID#: ___________________________________ Subscriber ID#: _______________________________________ Employers’ Address: ___________________________________ Is this insurance: HMO PPO POS EPO Indemnity

If the secondary insurance policy DOES restrict the medical providers the student-athlete may use, please enter the corresponding policy information below:

The Secondary Care Physician/ Medical Group is: ______________________________________________________________________ PCP/ Medical Group: _______________________________________________________Phone #: _______________________________ Address, City, Zip Code: ___________________________________________________________________________________________ Dental Insurance: Please include a copy of Insurance Cards (front & back). Company: ___________________________________________ City/State : _______________________ Zip ________________ Plan/Group #: ________________________________________ Subscriber Name: ______________________________________ Subscriber’s Employer: _________________________________ City/State: ________________________ Zip:_______________

Insurance Address: ____________________________________ Insurance Phone: _____________________________________ Policy/Member ID#: ___________________________________ Subscriber ID#: _______________________________________ Employers’ Address: ___________________________________ Is this insurance: HMO PPO POS EPO Indemnity

UC Irvine Sports Medicine ATHLETICS PARTICIPATION HISTORY QUESTIONNAIRE

Page 1 of 2

Athlete's Name: _________________________________________ Date of Birth: ______________ UCI Student ID #:_________________ Sport(s):___________________________ Year: 1 2 3 4 5 Cell Phone #: _____________________________________________

THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY EITHER YES OR NO.

PLEASE OFFER A WRITTEN EXPLANATION OF EACH YES ON PAGE 2.

Have you had or do you now have: Yes No Have you had or do you now have: Yes No • Seasonal allergies? • Very bad (impaired) vision in one eye? • Asthma (wheezing)? Used an Inhaler? • Missing vision in one eye? • Hay Fever? Pollens? • Temporary loss of vision? • Hives or Rash (With or without exercise)? Do you wear glasses or contacts? • Bee-sting allergy? Have you had or do you now have: • Reaction to medicine? • Hearing Loss? • Food allergies? • Perforated eardrum? Have you been under a doctor’s care since your last physical?

• Chronic discharge from the ear(s)? • Recurrent ear(s) infection(s)?

Have you been in the hospital since your last physical? Have you had or do you now have: • Loss of or absence of a testicle (men)?

Have you ever had any type of surgery? If yes, ________________________________________

• Loss of Spleen or any other Organ? • Kidney problem or loss of a kidney?

Have you or anyone in you immediate family ever had:

Yes Self

Yes Family No

• Hernia? Painful bulge in the abdominal area? • Persistent cough?

• Headaches (severe, frequent, migraine)? • Diabetes (high sugar in blood or urine)? • Heart trouble, murmur, racing heart? • History of Mono? • High Blood Pressure / Cholesterol? • Tendency to bleed or bruise easily? • Sickle cell trait or disease? • Anemia (“tired blood”)? • Marfan’s Syndrome / Kawasaki Disease? • Unusual Fatigue? • Heart Cardiomyopathy or Arrhythmia? Have you had or do you now have: • Seizure disorders or near drowning? • Sinus infections? Family history of a disabling heart / lung condition? • Dental plate/dentures? Has anyone in your family, under the age of 50, died suddenly?

• Orthodontics (teeth straightened) • Do you have a Bridge of False Teeth?

Have you had or do you now have: Have you had or do you now have: • Chest pain, tightness or discomfort with exercise? • Recurrent rash? • Ever passed out or nearly passed out DURING or

AFTER exercise or working out? • Fungus infection?

• Athlete’s foot? • Shortness of breath while playing or exercising? • Recurrent boils (skin infections)? • Dizziness or Faintness with exercise? • A history of Staph Infection? Ever become ill from working out in the heat? History of heat stroke, heat exhaustion, or heat cramps?

• MRSA or herpes skin infection? Have you had or do you now have: Any history of Attention Deficit Disorder (ADD) or

ADHD?

• Brain concussion / Knocked out? • A hit or blow to the head that caused confusion,

prolonged headache or memory problems? • Taking Medication for ADD/ADHD?

• Head injury or facial/skull fracture? Any history of learning Disabilities? • History of Migraines? Do you want to talk to a doctor about a health

problem or injury?

• Number of previous concussions _______ • Date of most recent concussion _______ Do you wish to discuss an emotional problem with

the doctor?

• Number of days missed after concussion _______

Page 2 of 2

Yes No Yes No Do you smoke? Do you eat three meals a day? Family history of smoking? Do you drink at least (8) 12oz glasses of water/day? Any problems with Alcohol or Drug Abuse? Any history of Disordered Eating? If yes, past or present? ______________________________________ Are you trying or has someone recommended that

you gain weight?

Family history of drug or alcohol abuse? Take any medicine regularly (Over The Counter, prescription or for emergencies)?

Are you trying or has someone recommended that you lose weight?

If Yes, name medication(s): Have you ever tried to lose weight by: _________________________________________________________ • Do you avoid certain types of food? _________________________________________________________ • Dieting? Special Diets? Take any vitamins, herbal or nutritional supplements? • Cleansing Diets? Purging? Vomiting? If yes, list below: • Using Diuretics? Laxitives? _________________________________________________________ Any history of Stress Fractures? _________________________________________________________ Had a sprain, strain or swelling after injury that has

kept you from participation in practices/games?

Have you ever been seen by a Heart Specialist? If Yes: Who: _____________________________________________ Identify below any location(s) with history of pain or swelling in

muscles, tendons, bones or joints. If yes, check the appropriate boxes corresponding to the body part and explain below: When: ____________________________________________

Have you ever had an EKG/ECG? Echocardiogram? Head Elbow Hip Have you ever had a stress (heart) test? Neck Forearm Thigh Have you been advised to give up sports because of a Back Wrist Knee health problem? Chest Hand Shin/Calf Have you had or do you have any other medical Shoulder Finger/Thumb Ankle problems or injuries not listed on this form? Upper Arm Foot/Toes If Yes: _________________________________________________ Had a pinched nerve, stinger or burner? Are there any additional health problems you would prefer to discuss privately with our Team Physician?

Had numbness/tingling in arms, hands, legs or feet? You or your family have a history of Juvenile

arthritis or a connective tissue disorder? Do you use special protective or corrective equipment or devices? Knee sleeves, knee braces, orthotics, etc. If yes: ________________________

If you have answered YES to any of the questions (page 1 & 2), please EXPLAIN below: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Female Only: Yes

No

Do you experience cramps? How old were you when you had your 1st period? ____________ Have you been diagnosed or treated for anemia? How long do your periods last? ____________ Do you have trouble with heavy bleeding? How often do you have your periods? ____________ Do you take birth control pills or hormones? How many periods have you had in the past 12 mo.? ____________ Have you ever had an abnormal PAP smear? When was your last pelvic exam? ____________ Do you have frequent urinary tract infections?

Additional comments, information or questions? __________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ I hereby certify that I have completed this questionnaire completely and correctly to the best of my ability and knowledge. I certify that there are no illnesses or injuries, current or previous, that I have incurred, other than those I have listed on the preceding pages. Signature of Athlete: _____________________________________________________________________ Date: ___________________ Signature of Parent (if under 18 at time of Physical): ____________________________________________ Date: ___________________ UCI Team Physician: _____________________________________________________________________ Date: ___________________ Physician Signature Physician Print Name

UC Irvine Sports Medicine PHYSICAL EXAMINATION RECORD

Athlete's Name: __________________________________ Date of Birth: ______________ UCI Student ID #:_______________ Sport(s):___________________________ Year: 1 2 3 4 5 Cell Phone #: ____________________________________

Height

Weight BMI BP Pulse Vision contacts glasses none R: 20/ L: 20/ B: 20/ .

Sickle Cell Trait Status ______________________ Date of Last Tetanus Booster (within 10 years) _____________________

***Must attach a copy of the sickle cell test results and immunization documents***

Regular Medications/Dosage: _______________________________________________________________________________________

___________________________________________________________________________________________________________________ Marfan’s Screen Indicated? Yes No NORMAL COMMENTS OR ABNORMAL FINDINGS Head, Neck, Face, Scalp

Nose Sinuses

Mouth and throat

Ears/ drums Eyes / pupils / ocular motility

Opthalmoscopic

Chest and Lungs

Breasts (male and female)

Heart (thrust size, rhythm, sounds)

Vascular system (pulses and varicosity)

Abdomen and viscera (hernias) G-U system

Anus and rectum Endocrine system

Upper extremities

Lower extremities Spine, other musculoskeletal

Skin / lymphatics Neurological

Psychiatric Pelvic and sexual maturation (Circle Tanner Stage) 1 2 3 4 5

Other (indicate)

Health Assessment Summary Cleared for Participation in _____________________ NOT Cleared for Participation in ______________________ Sport Sport No Significant Health Concern Significant Health Concern Found _____________________ ______________________________________ ____________________________________________

I have reviewed this form and certify that the information above is true, complete, and correct to the best of my ability Print Name: __________________________________________________Medical Professional Title: _____________________ (MD, DO, NP, or PA ONLY) Address: ____________________________________________________________ Phone #: ____________________________

Signature: __________________________________________ Date of Exam: ____________ License #: __________________

NCAA Banned Drugs and Medical Exceptions Policy Guidelines Regarding medical Reporting

For Student-Athletes with Attention Deficit Hyperactivity Disorder (ADHD) Taking Prescribed Stimulants

The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in competition. Some legitimate medications contain NCAA banned substances, and student-athletes may need to use these medicines to support their academics and their general health. The NCAA has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The diagnosis of adult ADHD remains clinically based utilizing clinical interviews, symptom-rating scales, and subjective reporting from patients and others. The following guidelines will help institutions ensure adequate medical records are on file for student-athletes diagnosed with ADHD in order to request an exception in the event a student-athlete tests positive during NCAA Drug Testing.

1. General considerations. Student-athletes diagnosed with ADHD in childhood should provide records of the ADHD assessment and history of treatment. Student-athletes treated since childhood with ADHD stimulant medication but who do not have records of childhood ADHD assessment, or who are initiating treatment as an adult, must undergo a comprehensive evaluation to establish a diagnosis of ADHD. There are currently no formal guidelines or standards of care for the evaluation and management of adult ADHD. The diagnosis is based on a clinical evaluation. ADHD is a neurobiological disorder that should be assessed by an experienced clinician and managed by a physician to improve the functioning and quality of life of an individual.

a. Student-athletes should have access to a comprehensive continuum of care including educational, behavioral, psychosocial and pharmacological services provided by licensed practitioners who have experience in the diagnosis and management of ADHD. Student- athletes treated with ADHD stimulant medication should receive, at a minimum, annual clinical evaluations.

b. Mental health professionals who evaluate and prescribe medical therapy for student-athletes with ADHD should have appropriate training and experience in the diagnosis and management of ADHD and should have access to consultation and referral resources, such as appropriate medical specialists.

c. Primary care professionals providing mental health services (specifically the prescribing of stimulants) for student-athletes with ADHD should have experience in the diagnosis and management of ADHD and should have access to consultation and referral resources (e.g., qualified mental health professionals as well as other appropriate medical specialists).

2. Recommended ways to facilitate academic, athletics, occupational and psychosocial success in the college athlete with adult ADHD taking prescribed stimulants include:

a. Access to practitioners experienced in the diagnosis and management of adult ADHD.

b. A timely, comprehensive clinical evaluation and appropriate diagnosis using current medical standards.

c. Access to disability services.

d. Appropriate medical reporting to athletics departments/sports medicine staff.

e. Regular mental health/general medical follow-up.

3. Student-Athlete Document Responsibility. The student-athlete’s documentation from the prescribing physician to the athletics departments/ sports medicine staff should contain a minimum of the following

information to help ensure that ADHD has been diagnosed and is being managed appropriately (see Attachment for physician letter criteria):

a. Description of the evaluation process which identifies the assessment tools and procedures.

b. Statement of the Diagnosis, including when it was confirmed.

c. History of ADHD treatment (previous/ongoing).

d. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed.

e. Statement regarding follow-up and monitoring visits.

4. Institutional Document Responsibility. The institution should note ADHD treatment in the student-athlete’s medical record on file in the athletics department. In order to request a medical exception for ADHD stimulant medication use, it is important for the institution to have on file documentation that an evaluation has been conducted, the student-athlete is undergoing medical care for the condition, and the student-athlete is being treated appropriately. The institution should keep the following on confidential file:

a. Record of the student-athlete’s evaluation.

b. Statement of the Diagnosis, including when it was confirmed.

c. History of ADHD treatment (previous/ongoing).

d. Copy of the most recent prescription (as documented by the prescribing physician)

e. Requesting an NCAA Medical Exception:

5. The student-athlete should report the banned medication to the institution upon matriculation or when treatment commences in order for the student-athlete to be eligible for a medical exception in the event of a positive drug test.

a. A student-athlete’s medical records or physician’s letter should not be sent to the NCAA, unless requested by the NCAA.

b. The use of the prescribed stimulant medication does not need to be reported at the time of NCAA drug testing.

c. Documentation should be submitted by the institution in the event a student-athlete tests positive for the banned stimulant.

Note: The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports may approve stimulant medication use for ADHD without a prior trial of a non-stimulant medication. Although the NCAA Medical Exception Policy requires that a non-banned medication be considered, the medical community has generally accepted that the non-stimulant medications may not be as effective in the treatment of ADHD for some in this age group.

ATTACHMENT

Attention Deficit Hyperactivity Disorder (ADHD) Guideline Attachment

Criteria for letter from prescribing Physician to provide documentation to the Athletics Department/Sports Medicine staff regarding assessment of student-athletes taking prescribed stimulants for Attention Deficit Hyperactivity Disorder (ADHD), in support of an NCAA Medical Exception request for the use of a banned substance. The following must be included in supporting documentation:

1. Student-athlete name. 2. Student-athlete date of birth. 3. Date of clinical valuation. 4. Clinical evaluation components including:

a. Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) -- attach supporting documentation.

b. ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report summary -- attach supporting documentation.

c. Blood pressure and pulse readings and comments. d. Note that alternative non-banned medications have been considered, and comments. e. Diagnosis. f. Medication(s) and dosage. g. Follow-up orders.

Additional ADHD evaluation components if available:

• Report ADHD symptoms by other significant individual(s). • Psychological testing results. • Physical exam date and results. • Laboratory/testing results. • Summary of previous ADHD diagnosis. • Other comments.

Documentation from prescribing physician must also include the following:

• Physician name (Printed) • Office address and contact information. • Specialty. • Physician signature and date.

DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and Treatment with Banned Stimulant

Medication

July 2018

• Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication.

• Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Medical Exceptions Procedures at www.ncaa.org/drugtesting).

To be completed by the Institution:

Please return this form to the student-athlete or to the following address: Institution Name: UC Irvine Intercollegiate Athletics Sports Medicine Institution Representative Submitting Form: Jim Pluemer MS, PT, ATC, CSCS

Assistant Athletic Director - Sports Medicine 903 Crawford Hall, Irvine CA, 92697-4500 Office: 949-824-7633 Fax: 949-824-1091

Student-Athlete Name Date of Birth Prescribed banned medication

To be completed by the Student-Athlete’s Physician:

Current Treating Physician (print name): ____________________________________________________________ Specialty: _____________________________________________________________________________________ Office Address: ________________________________________________________________________________ Physician signature: ________________________________________________________Date: ________________ Check off that documentation representing each of the items below is attached to this report

Diagnosis. Medication(s) and dosage. Has considered a non-banned medication alternative. Blood pressure and pulse readings and comments. Follow-up orders. Date of clinical evaluation: Attach written report summary of comprehensive clinical evaluation. Please note that this includes the

original clinical notes of the diagnostic evaluation. The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores. The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above.

DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

I hereby authorize and request a report associated with this visit be sent to UC Irvine Sports Medicine (fax: 949-824-1091) or by separate report via mail.

Patient’s Signature: _____________________________________________ Date: ________________

UC Irvine Sports Medicine AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

TO SPORTA MEDICINE

I authorize UC Irvine team physicians, athletic trainers, sports information staff and athletic coaches to release my health information concerning any illness or injury relative to my participation in athletics at UC Irvine to the athletic coaches, administrators, and sports information staff for legitimate educational purposes related to my participation in those sports. I understand that I cannot participate in my sport(s) without signing this release. This release will be effective for the time period of my participation in intercollegiate athletics at UC Irvine. Notice: UC Irvine Sports Medicine and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, state or federal confidentiality laws may no longer protect it. Your Rights: • I understand that the treatment, payment enrollment, or eligibility for benefits may not be conditioned on

signing this authorization except if the authorization is for: 1) conducting research-related treatment 2) to obtain information in connection with eligibility or enrollment in a health plan 3) to determine an entity’s obligation to pay a claim 4) to create health information to provide a third party.

• I may revoke this authorization at any time. To do so I must submit a written request to Jim Pluemer

Director of Sports Medicine, UC Irvine Athletics, Crawford Hall, Irvine, CA 92697-4500. The revocation will take effect when UC Irvine Sports Medicine receives it, except to the extent that UC Irvine Department of Intercollegiate Athletics or others have already relied on it.

• I am entitled to receive a copy of this Authorization. Signature: Athlete’s Signature Date

Athlete’s Printed Name Sport

Athlete’s Parent or Legal Guardian Signature (If Athlete is under age 18) Date

Athlete’s Parent or Legal Guardian Printed Name (If Athlete is under age 18)

Witness Signature (If Athlete is unable to sign) or Interpreter Date

UC Irvine Sports Medicine AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

TO UNIVERSITY STUDENT HEALTH SERVICES I authorize UC Irvine Team Physicians, Athletic Trainers, Sports Information Staff and Athletic Coaches to release my health information concerning any illness or injury relative to my participation in athletics at UC Irvine to University Student Health Services in order to facilitate medical care related to my participation in those sports.

University Student Health Services 501 Student Health – UC Irvine Irvine, California 92697-5200

Tel (949) 824-5301

I understand that I cannot participate in my sport(s) without signing this release.

This release will be effective for the time period of my participation in intercollegiate athletics at UC Irvine.

Notice:

UC Irvine Sports Medicine and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, state or federal confidentiality laws may no longer protect it.

Your Rights:

• I understand that the treatment, payment enrollment, or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related treatment 2) to obtain information in connection with eligibility or enrollment in a health plan 3) to determine an entity’s obligation to pay a claim 4) to create health information to provide a third party.

• I may revoke this authorization at any time. To do so I must submit a written request to Jim Pluemer Director of Sports Medicine, UC Irvine Athletics, Crawford Hall, Irvine, CA 92697-4500. The revocation will take effect when UC Irvine Sports Medicine receives it, except to the extent that UC Irvine Department of Intercollegiate Athletics or others have already relied on it.

• I am entitled to receive a copy of this Authorization.

Signature: Athlete’s Signature Date

Athlete’s Printed Name Sport

Athlete’s Parent or Legal Guardian Signature (If Athlete is under age 18) Date

Athlete’s Parent or Legal Guardian Printed Name (If Athlete is under age 18)

Witness Signature (If Athlete is unable to sign) or Interpreter Date

UC Irvine Sports Medicine AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

TO MEDIA I authorize UC Irvine Team Physicians, Athletic Trainers, Sports Information Staff and Athletic Coaches to release my health information concerning any illness or injury relative to my participation in athletics at UC Irvine to the media, including TV, radio, newspapers, or magazine media outlets for news stories, health care communications stories or for: _____________________________________ This release will be effective for the time period of my participation in intercollegiate athletics at UC Irvine. Notice: UC Irvine Sports Medicine and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, state or federal confidentiality laws may no longer protect it. Your Rights: • I understand that the treatment, payment enrollment, or eligibility for benefits may not be conditioned on

signing this authorization except if the authorization is for: 1) conducting research-related treatment 2) to obtain information in connection with eligibility or enrollment in a health plan 3) to determine an entity’s obligation to pay a claim 4) to create health information to provide a third party.

• I may revoke this authorization at any time. To do so I must submit a written request to Jim Pluemer

Director of Sports Medicine, UC Irvine Athletics, Crawford Hall, Irvine, CA 92697-4500. The revocation will take effect when UC Irvine Sports Medicine receives it, except to the extent that UC Irvine Department of Intercollegiate Athletics or others have already relied on it.

• I am entitled to receive a copy of this Authorization. Signature: Athlete’s Signature Date

Athlete’s Printed Name Sport

Athlete’s Parent or Legal Guardian Signature (If Athlete is under age 18) Date

Athlete’s Parent or Legal Guardian Printed Name (If Athlete is under age 18)

Witness Signature (If Athlete is unable to sign) or Interpreter Date

UC Irvine Sports Medicine AUTHORIZATION FOR MEDIA AND/OR PSYCHOLOGICAL TREATMENT OF A MINOR (LESS THAN 18 YEARS OF AGE)

I, _____________________________, am the parent or legal guardian of the student named above. I hereby authorize any healthcare provider at the University of California, Irvine Department of Intercollegiate Athletics Sports Medicine and/or Student Health Center to administer any medical and/or psychological treatment that is deemed necessary for the student named below. Full Name (Last, First): __________________________________________________________ Date of Birth: _________________________ Student ID #: ____________________________ __________________________________________________ _______________ Signature of Parent or Legal Guardian Date

How to Create a Sportsware Account Step 1: Go to www.swol23.net. Step 2: Click on the Athlete/Parent Button.

Step 3: Input UC Irvine’s School ID Code: 3302.

Step 4: Please input your information and your UCI email address.

Note: All other email addresses will be rejected.

Step 5: Wait patiently until you receive an email with the following instructions. Follow the link in

the email to set up your password. This may take 24-72 hours to complete.

Step 6: Set up your password.

Step 7: Return to www.swol123.net and login using your UCI email and password you just set up.

Step 8: This is what the screen will look like when you log in.

Step 9: Please click on the “here” button to complete your Athlete Information.

Step 10: Please click through and fill out each tab completely. Anything with a red asterisks (*)

will need to be filled out.

Step 11: Please upload a headshot of yourself.

Step 12: Make sure to hit “Save” and “Log out”.