Athlete Injury Form First Name* Last Name (first two letters only)* GradePlease Select6th7th8th9th10th11th12thCurrent sport/activity you’re involved in (check all that apply) Sport PE Strength & Conditioning School only What sport? What body part is bothering you? (check all that apply) Head/Face/Jaw Neck Upper/Mid Back Shoulder Elbow Wrist/Hand Low Back Hip Knee Ankle/Foot How did your problem come about?Please SelectI had a specific InjuryRepetitive activity with no specific injuryIt gradually came onI'm not sureDate of Injury? MM slash DD slash YYYY How did you injure yourself?Please provide as many details as possible.Have you been told you may have had a concussion or is it suspected that you did? Have you experienced any headaches, dizziness or fogginess/amnesia since your injury? No Yes Are you experiencing any of the following? Severe/debilitating headache Double vision Unequal pupils Convulsions Unusual/increased drowsiness Bleeding/clear fluid from the ear/nose Projectile or repeated vomiting Unusual stiffness in the neck area Severe personality changes Weakness in either arm(s) or leg(s) Numbness in the face/extremities Please call Wes Wickwar at 640-8186 to determine if the athlete needs to go to the Emergency Room. If you can’t get a hold of him, take athlete to the Emergency Room immediately.What problems are you experiencing? Headaches Dizziness/Lightheadedness Fogginess/Amnesia Sensitivity to light Sensitivity to sound Vision changes Balance problems Feeling sluggish, groggy or foggy Concentration/Memory problems Confusion What brings on your headaches or makes it worse?What lessens/takes away your headaches?What brings on your dizziness/lightheadedness or makes it worse?What lessens/takes away your dizziness/lightheadedness?What brings on your fogginess/amnesia or makes it worse?What lessens/takes away your fogginess/amnesia?What brings on your sensitivity to light or makes it worse?What lessens/takes away your sensitivity to light?What brings on your sensitivity to sound or makes it worse?What lessens/takes away your sensitivity to sound?What brings on your vision changes or makes it worse?What lessens/takes away your vision changes?What brings on your balance problems or makes it worse?What lessens/takes away your balance problems?What brings on your feeling of sluggishness/grogginess/fogginess or makes it worse?What lessens/takes away your feeling of sluggishness/grogginess/fogginess?What brings on your concentration/memory problems or makes it worse?What lessens/takes away your concentration/memory problems?What brings on your confusion or makes it worse?What lessens/takes away your confusion?When did you first notice your problem?What activity do you think caused your pain/problem?When did you first notice your pain/problem?What do you believe has caused your pain/problem?Have you had any diagnostic tests for this problem like X-rays, MRI’s or CT Scans?Please SelectYesNoWhat test(s) have been performed? X-ray MRI CT Scan Other What were the findings?What problems are you currently having? Pain Catching/Locking/Popping/Grinding Instability/Feeling like something is going to give out on you Weakness Stiffness or Tightness Swelling Numbness or Tingling Other When do you feel pain?Please SelectAlwaysNot AlwaysWhere do you feel pain?What brings on your pain or makes it worse? (Activities, movements or positions, etc)What lessens/takes away your pain? (Activities, movements, positions, treatments, medications, etc)What brings on your catching/locking/popping/grinding?What lessens/takes away your catching/locking/popping/grinding?What brings on your instability/feeling like something is going to give out on you?What lessens/takes away your instability/feeling like something is going to give out on you?What brings on your weakness or makes it worse?What lessens/takes away your weakness?What brings on your stiffness/tightness or makes it worse?What lessens/takes away your stiffness/tightness?What brings on your swelling or makes it worse?What lessens your swelling or takes it away?What brings on your numbness/tingling or makes it worse?What lessens/takes away your numbness/tingling?Please describe the problemPhoneThis field is for validation purposes and should be left unchanged.
