First Aid Treatment Form GSFC

FIRST AID TREATMENT FORM

Goodwood Saints Football Club
Incident Classification*
A major or significant Injury is likely to result in extended time out of football, any head injury/potential concussion and/or any injury likely to require further medical care / financial cost.
If the injury is minor, the player is able to return to play almost immediately, no further assessment is requested, all details included on the form are not required to be filled in.

A major or signifcant injury will show signs of:
- severe swelling and pain
- visible lumps, bumps, or other deformities
- popping or crunching sounds when you use the joint
- weakness or inability to put weight on the joint
- instability
PATIENT INFORMATION
Please select Player Group
Patient Name:*

First NameLast Name
Player/Parent or Guardian Contact Email *
example@example.com
Date of Birth:

DayMonthYear
Patient Phone Number*
It is essential to have a correct and valid phone number
If patient under 18 years of age, please provide parents name:

First NameLast Name
Parent Contact Phone Number:

Area CodePhone Number
Consent for Player Welfare Team (PWT) to contact - please note all head knocks and concussion MUST be reported to PWT*

YesNoMinor injury - not required
INCIDENT INFORMATION
Date of Incident:*

DayMonthYear
Minor Injury Details:

BruiseAbrasionStrainOther
Major Injury Details:*

Head knockConcussion - Please confirm use of HeadCheck assessment in description belowSprainFractureLacerationStrainMedical ConditionDentalOther
Click on the link below to download Headcheck app.

Pleases hold down control and then click to activate

Headcheck
Have you had a previous concussion?*

YesNo
Please indicate whether you have used Headcheck.

YesNo
Description of injury - If patient concussed, please provide all details:
If other, please describe the injury
Was the patient unconscious at any stage?

YesNo
Did the patient stop breathing at any stage?:

YesNo
Pulse:

YesNo
Location of Incident:
(For example - On oval, changerooms, grandstand)
Witnesses (if relevant):
Incident Description:
MEDICAL HISTORY - Significant Injury only
Allergies:
Previous Relevant Surgeries:
Current Medications:
TREATMENT INFORMATION
Date of treatment:*

DayMonthYear
Date
Please check the body parts that are given first aid.
Treatment Description:
Secondary medical care required
Pleaase provide details eg Ambulance Called or referred to GP
FIRST AIDER INFORMATION
First Aider Name:*

First NameLast Name
First Aider Email*
example@example.com
Phone Number*
Please enter a valid phone number.
First Aid Officer:*

Clear
Date:*

DayMonthYear
Date
Hour MinutesAM/PM Option
Should be Empty:

FIRST AID TREATMENT FORM