Waterloo Minor Soccer Club Injury Report Form

Waterloo Minor Soccer Club Injury Report Form Player Name: ________________________________________________ Phone Number: (_______)_______________________ Gender Male Female Date of Birth: ____/____/____ Today’s Date: ____/____/____ Time: ____: ____ am/pm (circle) Event: Game Practice Location: ___________________________________________ Team: ___________________________________________ Team Official Present: Coach/Manager/Assistant Coach (Circle) TYPE OF ACTIVITY A T TIME OF INJURY  Training  Warm-­‐up  Competition  Cool-­‐down  Other: _________________________ INJURY STATUS  New injury  Aggravated injury  Recurrent Injury  Illness  Other __________________________ BODY PARTS INJURED Circle and Name NATURE OF INJURY/ILLNESS  Bruise/contusion  Cardiac problem  Cold/flu  Concussion  Dislocation/subluxation  Fracture (including suspected)  Inflammation/swelling  Loss o f consciousness  Overuse injury  Respiratory problem  Skin injury  Sprain (ie: Ligament tear)  Strain (ie: Muscle tear)  Unspecified medical condition  Other __________________________ SUSPECTED CAUSE OF INJURY  Collision with fixed object  Collision with other player  Fall from height/awkward landing  Jumping to shoot or defend  Overexertion  Overuse  Slip/trip/fall/stumble  Struck by ball/object  Struck by o ther player  Temperature related  Other_______________________ EXPLAIN HOW THE INCIDENT OCCURRED ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ IN YOUR OPINION, WERE THERE ANY CONTRIBUTING FACTORS TO THE INCIDENT? Ie: unsuitable footwear, playing surface, equipment, foul play _____________________________________________ _____________________________________________ _____________________________________________ WAS PROTECTIVE EQUIPMENT WORN ON THE INJURED BODY PART? Yes No If yes, what? (mouthguard, brace, etc) ______________________________________________ ______________________________________________ INITIAL ATTENDANCE  None given  CPR  Dressing  Immobilization  RICER  Splint/sling  Strapping/tapping  Transport from field  SCAT2  Other ____________________________ ADVICE GIVEN 
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Unable to return at present Referred for further assessment before returning to activity Return to play w ith restriction _________________________________ _________________________________ Immediate return to activity NOTICE The injured person was advised that if the injury/illness does NOT improve in the following 24 hours they MUST seek further medical advice from their medical professional. Yes No Signature of Team Official: X:________________________________________ Date: ___/___/___ Signature of Witness: (ie: Trainer, Parent) X:________________________________________ Date: ___/___/___ Signature of Injured Person/Legal Guardian: X:________________________________________ Date: ___/___/___