=========================================================
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.
