Appendix A Cleveland State University Sports Medicine printable pdf download

Appendix A

Cleveland State University Sports Medicine

ADD/ADHD NCAA Compliance Form

Adapted from the NCAA Medical Exception Documentation Reporting Form to Support the

Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)

and Treatment with Banned Stimulant Medication

Name of Student Athlete:_______________________________________ DOB:_____________

Treating Physician:______________________________ Specialty:_______________________

Office Address:_________________________________________________________________

Office Phone:_________________________________ Fax:_____________________________

Required Documentation:

1. Date of Last Evaluation:__________________ Next Scheduled Visit:___________________

2. Follow-up orders:____________________________________________________________

3. BP:_________Pulse__________Comments:_______________________________________

4. Diagnosis: ADD________ADHD________Other__________________________________

5. Medication(s) and dosage (Attach copy of recent prescription):

_________________________________________________________________________________

_____________________________________________________________________

6. Note that alternative non-banned medications have been considered, and comments:

_________________________________________________________________________________

_____________________________________________________________________

7. Attach written report summary of comprehensive clinical 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.

Provider signature:____________________________________ Date:_____________________

Student Athlete: Please complete the following:

I, _______________________________give______________________________ permission to release

all information regarding my treatment for ADD/ADHD to the Cleveland State University Sports

Medicine Department, Team Physicians, and the National Collegiate Athletic Association. 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 Head Athletic Trainer, with

the understanding that all information released prior to my revocation is excluded. My signature below

indicates that I have read and understand the above statement.

Student Athlete Signature____________________________________Date:________________

Appendix A Cleveland State University Sports Medicine