Sideline Injury Report Form for Team Doctors or Trainers

My contribution to volunteer team doctors.  Use and modify as you like.  I think you should just be able to copy and paste into your favorite word processor. I use OpenOffice.org and it formats nicely in it to just 1 side of a 8.5"x11" page by picking Optimum under the graphics text wrapping options.   You will probably have to massage the graphics a bit with text wrapping and resizing.  Graphics were obtained off the internet. Do not charge to use these unless you pay the graphics owners, if any!  (and if you charge for sidelines care, or get paid in any way, then you better have malpractice insurance!)

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SIDELINE INJURY REPORT FORM

Date: _______________ INJURY TIME: ______________

PLAYER/Official: ________________________________________

INJURY: ________________________________________________________________________

COMPLAINTS: __________________________________________________________

INJURY DESCRIPTION:

approp vitals:

INITIAL RED FLAGS?

Loss Of Consc: YES NO “Near LOC”

Head Pain: YES NO

Neck Pain: YES NO

C/M/S intact YES NO

Immed Swelling YES NO

Able to bear wt YES NO

Relevant Med Hx:

TREATMENT:

____________________________________________

____________________________________________

ASSESSMENT:________________________________________________

PLAN: _______________________________________________________

RETURN TO PLAY: YES NO

SIDELINE HOLD: YES NO

SENT TO ER: YES NO Ambulance called: _____________

FOLLOW-UP ADVISED :

WITH USUAL MD: YES IF STILL PROBLEMS IN ________ DAYS

WITH SPECIALIST: YES IF STILL PROBLEMS IN ________ DAYS

REPORT TO PARENT YES COPY E-MAILED TO COACH: YES COPY SAVED FOR ME: YES

signed: ___________________________________

                   (YOUR NAME HERE)

Disclaimer:

Evaluation and Treatment provided during games and practice is totally voluntary and without reimbursement. Any care provided is not done on behalf of, or for my usual employers, and in no way represents them. Parents or adults should follow-up any concerns with their own physician or hospital ER.