Football Injury Reporting Form - Australia

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AUSTRALIAN FOOTBALL INJURY REPORTING FORM
Name: _________________________________ Initials: _____ Position: _______________________
Circle
Player/Umpire/Coach/Spectator
Team :_________________________ Grade: ___________
DOB: __/__/__
Gender: M
F
Venue/area at which injury occurred: ____________________
Explain exactly how the incident occurred
Date of Injury
__/__/__
Nature of Injury/Illness
Advice Given
_________________________________
abrasion/graze
immediate return unrestricted activity
_________________________________
Type of activity at time of injury
open wound/laceration/cut
able to return with restriction
bruise/contusion
__________________________________
unable to return at present time
training/practice
inflammation/swelling
__________________________________
competition
fracture (including suspected)
__________________________________
other _________________________
Referral
dislocation/subluxation
__________________________________
no referral
sprain eg ligament tear
__________________________________
medical practitioner
Reason for Presentation
strain eg muscle tear
__________________________________
physiotherapist
new injury
overuse injury to muscle or tendon
__________________________________
chiropractor or other professional
exacerbated/aggravated injury
blisters
__________________________
ambulance transport
recurrent injury
concussion
hospital
illness
cardiac problem
Were there any contributing factors to the
other __________________________
other __________________________
respiratory problem
incident, unsuitable footwear, playing
loss of consciousness
surface, equipment, foul play?
Provisional severity assessment
Body Region Injured
unspecified medical condition
__________________________________
mild (1-7 days modified activity)
Tick or circle body part/s injured & name
other __________________________
__________________________________
moderate (8-21 days modified activity)
_______________________________
severe (>21 days modified or lost)
Provisional diagnosis/es _____________
_________________________________
Protective Equipment
Treating person
Was protective equipment worn on the
medical practitioner
_________________________________
injured body part?
yes
no
physiotherapist
nurse
CAUSE OF INJURY
If yes, what type eg mouthguard, ankle
sports trainer
Mechanism of Injury
brace, taping.
other __________________________
struck by other player
_________________________________
struck by ball (eg dislocated finger)
collision with other player/referee
Signature of treating person
Initial Treatment
collision with fixed object (goal post)
__________________________________
none given (not required)
fall/stumble on same level
________________________________
RICER
dressing
jumping
sling, splint
crutches
landing from jump
Today’s Date:
__/__/__
massage
manual therapy
slip/trip
CPR
stretch/exercises
twisting to pass or accelerate
Body part/s
strapping/taping only
overexertion (eg muscle tear)
_________________________________
none given - referred elsewhere
overuse
other __________________________
temperature related eg heat stress
_________________________________
other _________________________
AUSTRALIAN FOOTBALL INJURY REPORTING FORM
Name: _________________________________ Initials: _____ Position: _______________________
Circle
Player/Umpire/Coach/Spectator
Team :_________________________ Grade: ___________
DOB: __/__/__
Gender: M
F
Venue/area at which injury occurred: ____________________
Explain exactly how the incident occurred
Date of Injury
__/__/__
Nature of Injury/Illness
Advice Given
_________________________________
abrasion/graze
immediate return unrestricted activity
_________________________________
Type of activity at time of injury
open wound/laceration/cut
able to return with restriction
bruise/contusion
__________________________________
unable to return at present time
training/practice
inflammation/swelling
__________________________________
competition
fracture (including suspected)
__________________________________
other _________________________
Referral
dislocation/subluxation
__________________________________
no referral
sprain eg ligament tear
__________________________________
medical practitioner
Reason for Presentation
strain eg muscle tear
__________________________________
physiotherapist
new injury
overuse injury to muscle or tendon
__________________________________
chiropractor or other professional
exacerbated/aggravated injury
blisters
__________________________
ambulance transport
recurrent injury
concussion
hospital
illness
cardiac problem
Were there any contributing factors to the
other __________________________
other __________________________
respiratory problem
incident, unsuitable footwear, playing
loss of consciousness
surface, equipment, foul play?
Provisional severity assessment
Body Region Injured
unspecified medical condition
__________________________________
mild (1-7 days modified activity)
Tick or circle body part/s injured & name
other __________________________
__________________________________
moderate (8-21 days modified activity)
_______________________________
severe (>21 days modified or lost)
Provisional diagnosis/es _____________
_________________________________
Protective Equipment
Treating person
Was protective equipment worn on the
medical practitioner
_________________________________
injured body part?
yes
no
physiotherapist
nurse
CAUSE OF INJURY
If yes, what type eg mouthguard, ankle
sports trainer
Mechanism of Injury
brace, taping.
other __________________________
struck by other player
_________________________________
struck by ball (eg dislocated finger)
collision with other player/referee
Signature of treating person
Initial Treatment
collision with fixed object (goal post)
__________________________________
none given (not required)
fall/stumble on same level
________________________________
RICER
dressing
jumping
sling, splint
crutches
landing from jump
Today’s Date:
__/__/__
massage
manual therapy
slip/trip
CPR
stretch/exercises
twisting to pass or accelerate
Body part/s
strapping/taping only
overexertion (eg muscle tear)
_________________________________
none given - referred elsewhere
overuse
other __________________________
temperature related eg heat stress
_________________________________
other _________________________

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