• Reserve m

Meet your Skipjacks Sports Medicine Team

Dr. Kevin Valvano is a board-certified Sports Medicine Physician working for WellSpan Health. He obtained his medical degree from the West Virginia School of Osteopathic Medicine, where he learned the art of manual treatments, in addition to traditional medicine. He subsequently completed his Family Medicine training at Michigan State and his Sports Medicine training at Virginia Tech, while working with their student-athletes. In addition to the Skipjacks, he also serves as the team physician for York Tech High School and the York Revolution. Dr. Valvano continues to enjoy participating in athletics, such as hockey and soccer. In his past, he played semi-professional roller hockey as a participant in the Professional Inline Hockey Association. He enjoys using his athletic background to continue to provide elite care for his athletes. Nicole is a licensed athletic trainer working in the WellSpan Sports Medicine department in both York and Lancaster Counties. She currently provides medical care for the Skipjacks Hockey Club and works alongside physicians to evaluate and treat injuries. She was a student-athlete at Messiah College where she graduated in 2018 with her bachelor’s degree in Athletic Training. She has experience treating semi-pro baseball athletes, as well as collegiate, high school, middle school, and recreational athletes. Her special interests include injury prevention, evaluation, and helping the athletes through injury recovery in their late-stage return-to-play. The WellSpan Sports Medicine team includes highly skilled orthopedic surgeons, primary care physicians, concussion specialists, licensed athletic trainers, physical therapists, sports nutritionists and sports psychologists.

24/7 Injury Hotline: (877) 482-5420 WellSpan.org/SportsMedicine

Kevin Valvano, DO, CAQSM

Nicole Wilkerson, LAT, ATC

WellSpan Sports Medicine understands the unique needs of athletes, parents, coaches and

active individuals both on and off the playing field. Our team provides an array of services

designed to prevent injuries through education, awareness and proper training, and to carefully

treat and rehabilitate injured athletes so that they may safely return to athletics as soon as

possible.

WellSpan participates with many, but not all insurance companies. This means we have

signed a contract with them to provide care for the people they cover. The contracts are not all

the same, and certain services may not be covered or may result in out-of-pocket costs depending

on your employee health benefits and your particular insurance network. Since most of our

Skipjack’s players medical coverage is based out of town, we suggest contacting your medical

insurance provider to determine any estimated costs your may encounter if in the event your child

needs medical care while playing for the Skipjacks in York, PA.

2020-2021 SKIPJACKS HOCKEY PREPARTICIPATION HEALTH QUESTIONAIRE FORM

PLEASE PRINT CLEARLY WITH BLUE OR BLACK INK. PLEASE DO NOT FOLD.

The contents of this form will be kept confidential as part of your medical records and will only be used to help your medical team take better care of you.

Name: Date of Birth: Last First Middle Initial 00/00//0000 Home Address: Street City State Zip Season Address: Street City State Zip Home Phone: Cell: (000) 000-0000 (000) 000-0000 Email Address: Soc Sec. No: For Emergency Use Only Family Doctor: Phone Number: Address: Street City State Zip IN CASE OF AN EMERGENCY, PLEASE CONTACT: Primary Emergency Contact: Name: Relationship: Last First Home: Cell: Work: Email Address: _____________________________________ Secondary Emergency Contact: Name: Relationship: Last First Home: Cell: Work: Email Address: ________________________________________________

Player Personal Insurance Information PLEASE PRINT CLEARLY WITH BLUE OR BLACK INK. PLEASE DO NOT FOLD.

Submitting your personal insurance information will assist the medical staff to find you appropriate treatment should you become ill. If you DO NOT have personal insurance, please sign the line below: I, ___________________________________________________ do not have personal health insurance Print Name: First and Last Signature: Date: If you do have personal health insurance, please complete the following: Name: Name of Policy Holder: As it appears on Insurance Card Your Relationship to the Policy Holder (Please circle one): I am the Policy

Holder Wife Mother Father Legal Guardian Other

If “Other,” please explain: Insurance Carrier: Policy/ID Number: e.g. Blue Cross Blue Shield / South Central Preferred Group Name: Group Number: Insurance Contact Information: Customer Service: Pre-Certification:

(These telephone numbers are typically located on the back of your insurance card) Clams Address: Street City State Zip

Permission to be Evaluated and Treated In the event of an emergency requiring medical attention, I expect every reasonable attempt to be made to ensure my safety and well-being. In an emergency or injury, I grant permission for medical treatment which includes any immediate treatment deemed necessary by the certified athletic trainer, medical staff, physicians and doctors, EMT staff, emergency room staff, and other medical staff. If necessary, I grant permission for the medical staff to transfer me to a qualified medical facility. I give permission for team personnel to contact my emergency contacts. I grant permission to the medical staff to render treatment, medical/surgical procedures, and injury prevention treatment necessary to maintain my health and well-being. Also, I grant permission for treatments, therapy, and game/ practice day taping be employed as may be deemed medically necessary or advisable in the diagnosis and treatment of my illness or injuries sustained through participation with the Skipjacks Hockey Club. ______________________________________________________________ ______________________________ Signature Date

Authorization to Disclose Medical Information in an Emergency

The purpose of this section is: 1) When you become injured or have a past injury/illness, your medical information may need to be shared between the Skipjacks Hockey Medical Staff (Team Physicians and Certified Athletic Trainers) and team coaches in order to provide you with the medical care needed and to determine when you are medically safe to return to hockey activity. I will allow the Skipjacks Hockey Medical Staff to disclose my daily injury status, including return to play recommendations, to the Skipjacks Hockey Club coaching staff. 2) In the event of an emergency, injury, or the event that you are unconscious, the Skipjacks Hockey Medical Staff must communicate effectively and efficiently to ensure that you receive proper care and treatment. The Skipjacks Hockey Medical Staff must communicate with each other and discuss or disclose your current emergency status, current injury status, and your past medical history to other trained medical personnel to assist in your care. This may include a serious emergency when you need to go to the hospital in an ambulance or a smaller injury where you need to be taken off the ice and evaluated by the Skipjacks Hockey Medical Staff. In the event that an emergency or injury occurs at an away game, you may need to be evaluated by the host team’s medical staff. Therefore, your current emergency status, current injury status, and past medical history must be discussed between medical personnel involved in your care.

3) During an emergency or in the event that I am injured, I understand that it is necessary for the Skipjacks Hockey Medical Staff to disclose my current injury status and/or medical history to facilitate my medical care. I understand that my current injury status and/or medical history may be disclosed to the ambulance EMT staff, physicians and doctors and team certified athletic trainers, emergency room personnel, Skipjacks Hockey coaches, other medical staff, and Skipjacks Hockey management personnel to ensure that I receive proper medical care in the event of an emergency, injury, or I am unconscious and need advanced medical care. 4) It is the policy of the Skipjacks Hockey Medical Staff to share your information only for the reasons described above. Your information will not be shared with media, fans, other players, coaches from other teams, or other parties who do not need to know your medical information. For my medical safety and the reasons stated above, I have read the above disclosure and agree to the conditions stated above. ______________________________________________________________ ______________________________ Signature Date

For players under the age of 18 years old for the 2020-2021 Skipjacks Hockey. This is a consent to treat without your presence in the event of immediate need for care.

MEDICAL CONSENT AUTHORIZATION

I, _____________________________, am the parent of the child listed below and there are no court orders now in effect

that would prohibit me from giving this consent.

OR I, ______________________________, am the legal guardian or legal custodian of the child by court order (copy

attached, if available) and there are no other court orders in effect that would prohibit me from giving this consent.

I give ________________________, residing at ________________________________________ (name of adult) (adult’s address) the power to consent to necessary medical or mental health treatment for the following child:

__________________________, born on____________________.

The person named above may consent to the child's (cross out all that do not apply): medical, dental, surgical,

developmental and/or mental health examination or treatment and may have access to any and all records, including, but

not limited to, medical, dental, school and insurance records, in order to make decisions regarding any such services.

This document shall remain in effect:

( ) until ____________________________ (specify a date) ( ) from ____________________________ to _________________________ (date range) ( ) until revoked by me in writing. Today’s date__________________________ ______________________________________________ (Parent/Guardian Printed Name) ______________________________________________ (Parent/Guardian Signature) ______________________________________________ (Witness Printed Name) ______________________________________________ (Witness Signature)

2020 SKIPJACKS HOCKEY Pre-participation Physical Exam

Date ____/____/________

NAME____________________________________________ DOB__________ (Last) (First) (MI) Please read all questions carefully and respond by circling the answers in the left margin. MEDICAL HISTORY YES NO 1.* Have you ever passed out or become extremely dizzy while exercising? YES NO 2.* Have you ever developed chest pain while exercising? YES NO 3.* Do you get tired more quickly than your friends do during exercise? YES NO 4.* Have you ever been told that you have a heart murmur? YES NO 5.* Have you ever had racing of your heart or skipped beats? YES NO 6.* Did you ever have any heart problems as a child?

YES NO 7.* Has a physician ever denied or restricted your participation in sports for any heart problems? YES NO 8. Do you currently, or did you ever, have asthma? YES NO 9. Do you cough frequently after exercise? ____________________________________________________________________________________________________________________________________________________________________________________ Examiner’s Notes – Details of pertinent YES answers: Question #

Have you ever been told that you have or had one of the following? YES NO 10.* COVID-19 YES NO 11. Cancer YES NO 12. Vertebral dissection YES NO 13. Stroke YES NO 14. Sickle cell trait YES NO 15. High blood pressure YES NO 16. Diabetes (high blood sugar) YES NO 17. High cholesterol YES NO 18. Anemia (low blood count) YES NO 19. Low iron YES NO 20. Liver disease or hepatitis YES NO 21. Epilepsy, seizures, or fits YES NO 22. Bladder infections YES NO 23. Kidney infections, kidney stones, or other kidney disease YES NO 24. Blood in your urine YES NO 25. Mononucleosis (mono) YES NO 26. Any significant illness not noted above YES NO 27. Have you ever become ill from exercising in the heat? YES NO 28. Do you have problems with muscle cramps with exercise? YES NO 29. Have you ever had an operation? YES NO 30.* Are you missing one of any paired organ (Eyes, Kidneys, Lungs, Testicles)? 31. Please list any medications you are currently taking ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ YES NO 32. Have you ever had a bad reaction or are you allergic to any medication? If yes, list the medications and the reaction you had to them______________________________________ ______________________________________________________________________________ YES NO 33. Are you allergic to any insect bites or stings? YES NO 34. List any other allergies________________________________________________ YES NO 35. Do you feel stressed out? YES NO 36. Have you ever seen anyone for depression or a stress-related problem? ____________________________________________________________________________________________________________________________________________________________________________________ Examiner’s Notes – Details of pertinent YES answers: Question #

PERSONAL HABITS YES NO 37. Do you drink alcohol? If yes, How much? ____________________________

How often? _____________________________ YES NO 38. Do you use tobacco products ? If yes, How much? ____________________________

How often? _____________________________ YES NO 39. Do you use any performance-enhancing drugs? If yes, which ones? ___________________ ______________________________________________________________________________ YES NO 40. Do you use any recreational drugs other than alcohol or tobacco? If yes, which ones? ____ ______________________________________________________________________________ YES NO 41. Do you ever engage in unprotected sexual activity?

NUTRITION 42. How many meals a day do you generally eat? ______________ 43. How many snacks a day do you generally eat? ______________ YES NO 44. Are there certain food groups you refuse to eat (meat, dairy, etc.) _____________________ YES NO 45. Do you have food allergies? Please list ____________________________________________ YES NO 46. Do you take any vitamin, mineral, or nutritional supplements? Please list _____________ 47. What is your highest adult weight? ___________________ 48. What is your lowest adult weight? ___________________ YES NO 49. Would you like to change your current weight? If so, what would you like to weigh? _______ YES NO 50. Have you ever used any technique other than diet to control your weight? YES NO 51. Have you ever been diagnosed with an eating disorder? ____________________________________________________________________________________________________________________________________________________________________________________ Examiner’s Notes – Details of pertinent YES answers: Question #

FAMILY HISTORY YES NO 52.* Has anyone to whom you are blood-related died suddenly before the age of 50?

YES NO 53.* Has anyone in your family been diagnosed with Marfan's Syndrome? YES NO 54. Do you have any family members who have Sickle Cell disease? YES NO 55. Are there any medical problems in your immediate family (parents, siblings)?

EYES, EARS, AND DENTAL

Have you experienced or do you use any of the following? YES NO 56. Complete or near complete loss of vision in either eye (not just needing glasses) YES NO 57. Hearing loss in either ear YES NO 58. Broken bones in the face YES NO 59. Glasses or contacts

CONCUSSION YES NO 60.* Have you ever had a concussion? If yes, how many?______________ YES NO 61. Have you ever had prolonged headaches, nausea, blurred vision, or difficulty concentrating after a head injury?

HEAD Have you ever had any of the following? YES NO 62. Surgery on your head (not just stitches) YES NO 63. Very frequent or severe headaches YES NO 64. Fainting spells YES NO 65. Seizures ____________________________________________________________________________________________________________________________________________________________________________________ Examiner’s Notes – Details of pertinent YES answers: Question #

ORTHOPEDIC HISTORY

NECK Have you ever had any of the following?

YES NO 66. Strained or sprained neck YES NO 67.* Fractured (broken) neck YES NO 68. Pinched nerve, stinger, or burner YES NO 69. Whiplash YES NO 70. Neck surgery

BONES AND JOINTS YES NO 71. Have you had a fracture (broken bone) in the past three years? YES NO 72. Have you had any stress fractures in the past? YES NO 73. Do you have a pin, screw, or plate in your body as a result of bone or joint surgery? YES NO 74.* Do you currently have any incompletely healed injuries (fractures, strains, or sprains)?

Shoulder Have you had any of the following shoulder problems that has made you stop competing or training? YES NO 75. Dislocation or subluxation (shoulder popped out) YES NO 76. Rotator cuff strain, tendinitis, bursitis, or impingement YES NO 77. Shoulder (A-C joint) separation YES NO 78. Shoulder surgery

Elbow Have you had any of the following elbow problems that has made you stop competing or training?

YES NO 79. Pain, sprains, strains, or tendinitis YES NO 80. Dislocation YES NO 81. Fractures YES NO 82. Elbow surgery

Wrist & Hand Have you had any of the following wrist/hand problems that has made you stop competing or training? YES NO 83. Sprain or strain YES NO 84. Fracture (broken wrist, hand, or finger) YES NO 85. Dislocation (fingers) YES NO 86. Wrist or hand surgery ____________________________________________________________________________________________________________________________________________________________________________________ Examiner’s Notes – Details of pertinent YES answers: Question #

Back

Have you had any of the following back problems that has made you stop competing or training? YES NO 87. Low back sprain or strain YES NO 88. Scoliosis YES NO 88. Disc injury YES NO 90. Pain shooting down the leg YES NO 91. Kidney injury

YES NO 92. Stress fracture, spondylolysis, or spondylolisthesis YES NO 93. Back surgery YES NO 94. Have you recently been experiencing any back pain?

Hip Have you had any of the following hip problems that has made you stop competing or training?

YES NO 95. Sprain or strain YES NO 96. Labral tear YES NO 97. Fracture in or around the hip YES NO 98. Hip surgery YES NO 99. Groin pain YES NO 100. Do you currently have any hip or groin pain?

Knee Have you had any of the following knee problems that has made you stop competing or training?

YES NO 101. Sprain or ligament injury YES NO 102. Cartilage (meniscus) injury YES NO 103. Fracture in or around the knee YES NO 104. Knee surgery YES NO 105. Do you frequently experience pain, grating, or popping around the kneecap? YES NO 106. Do you currently have any pain in or around your knee?

Leg, Ankle & Foot

Have you had any of the following problems that has made you stop competing or training? YES NO 107. Shin splints YES NO 108. Sprain YES NO 109. Dislocation YES NO 110. Fracture YES NO 111. Plantar fasciitis or heel spur YES NO 112. Do you currently have any leg, ankle or foot pain? Signature of Athlete _______________________________________________________ Date_____________________ ____________________________________________________________________________________________________________________________________________________________________________________ Examiner’s Notes – Details of pertinent YES answers: Question # PHYSICAL EXAM (this section is for the medical staff to complete on the day of physicals) Player Name ________________________________ Position ___________________________________ VITALS Height Weight Heart Rate Blood Pressure

Vision: OU: 20/ OD: 20/ OS: 20/ Corrected Vision: OU: 20/ OD: 20/ OS: 20/

MEDICAL NL N/A ABNORMAL FINDINGS

APPEARANCE

SKIN

HEENT

LYMPH NODES

HEART: SUPINE

HEART: UPRIGHT

HEART: VALSALVA

HEART: SQUATTING

LUNGS

ABDOMEN

NEURO

Name of Examiner: _________________________________________Date: _____________ (Examiner will note any recommendations on final page) Player Name ________________________________ Position ___________________________________ ORTHOPEDIC NL N/A ABNORMAL FINDINGS

NECK

BACK

SHOULDER/ UPPER ARM

ELBOW/ FOREARM

WRIST/HAND

HIP/THIGH

KNEE

LOWER LEG

ANKLE

FOOT

Name of Examiner: _________________________________________Date: _____________ (Examiner will note any recommendations on final page)

Clearance for Sports Participation

PLAYER NAME____________________________________________ DOB__________

Follow-up Recommendations (including appointments, records request, imaging, rehabilitation, etc.): FOLLOW-UP

WITH REASON REQUIRED RECOMMENDED

CLEARANCE Cleared to participate Cleared to participate, but must follow-up as noted above Limited clearance to participate Limitations: ____________________________ ____________________________ ____________________________ Not cleared to participate until follow-up noted above is completed Not cleared to participate Signature: _________________________________________ Date: _____________ Address: 2319 S. George St. York, PA 17403 Phone: (717) 812 – 4090