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Download GARNER SENIOR HIGH SCHOOL SPORTS MEDICINE
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C34 SPORTS MEDICINE INJURY REPORT FORM NAME: _____________________________________________________ DATE OF INJURY: _____/_____/_____ DATE: _____/_____/_____ SPORT: ______________________ CLASS OF _____________ TYPE OF INJURY: ___________________________________ ACUTE: ________ CHRONIC: _______ SITE OF INJURY: Right _______ Left _______ Medial _______ Lateral: _______ Anterior: _______ Superior: _______ Inferior: _______ Posterior: _______ AREA OF INJURY: ______ Knee ______ Low Back ______ Abdomen ______ Shoulder ______ Lower Leg ______ Groin ______ Chest ______ Elbow ______ Ankle ______ Buttocks ______ Neck ______ Wrist ______ Foot ______ Quadriceps ______ Head ______ Hand ______ Toes ______ Hamstring ______ Face ______ Fingers Other / Specific ______________________________________________________________________ HISTORY (How, When, Where, Mechanism): ____________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ PHYSICAL EXAM: Bleeding: _______________________________________ Deformity: __________________________ Swelling / Effusion: _____________________________________ Pain: _________________________ Range of Motion: (ROM): ______________________________________________________________ Strength: ____________________________________________________________________________ Ligamentous / Speciality Stability: _______________________________________________________ Functional: __________________________________________________________________________ Other: ______________________________________________________________________________ ____________________________________________________________________________________ IMPRESSION: _____________________________________________________________________________ DISPOSITION: __________ ICE, PIE ___________ Contrast ___________ Non-weight bearing __________ Ice Massage ___________ Moist Heat ___________ No activity __________ Ice Slush ___________ ROM, Stretch ___________ Rehab __________ Cryocuff ___________ EMS ___________ EMS Transport / ER __________ Whirlpool ___________ Ultrasound ___________ Referred to Physician Other __________________________________________________________________________________ EXAMINING TRAINER: _________________________________________________________________ High School Athletic Manual
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